1245739879 NPI number — GEORGIA PINES COMMUNITY SERVICE BOARD

Table of content: (NPI 1245739879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245739879 NPI number — GEORGIA PINES COMMUNITY SERVICE BOARD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA PINES COMMUNITY SERVICE BOARD
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:
1245739879
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1102 SMITH AVE STE K
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THOMASVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31792-5740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
407 CLOVERDALE DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THOMASVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31792
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-233-8904
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/09/2018

Additional Information

Authorized Official

Authorized Official Last Name:
NORMAN
Authorized Official First Name:
JONAS
Authorized Official Middle Name:
Authorized Official Title or Position:
CLERICAL SUPPORT
Authorized Official Telephone Number:
229-225-5031

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000754795H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com