1225091028 NPI number — STEPHENS COUNTY BOARD OF HEALTH

Table of content: (NPI 1225091028)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225091028 NPI number — STEPHENS COUNTY BOARD OF HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEPHENS COUNTY BOARD OF HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225091028
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
64 BOULEVARD STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOCCOA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30577-3010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-282-4507
Provider Business Mailing Address Fax Number:
706-282-4511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
64 BOULEVARD STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOCCOA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30577-3010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-282-4507
Provider Business Practice Location Address Fax Number:
706-282-4511
Provider Enumeration Date:
04/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WESTFALL
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
N
Authorized Official Title or Position:
HEALTH DIRECTOR
Authorized Official Telephone Number:
770-535-5743

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00051972K , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000924679C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00453109K , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00649437G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00058638A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00442945L , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00456442D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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