1588679203 NPI number — TMC WEST GEORGIA BEHAVIORAL HEALTH INC

Table of content: (NPI 1588679203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588679203 NPI number — TMC WEST GEORGIA BEHAVIORAL HEALTH INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TMC WEST GEORGIA BEHAVIORAL HEALTH INC
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:
6
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:
1588679203
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 QUARTZ DR
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
VILLA RICA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30180-3255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-456-3722
Provider Business Mailing Address Fax Number:
770-456-3739

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 QUARTZ DR
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
VILLA RICA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30180-3255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-456-3722
Provider Business Practice Location Address Fax Number:
770-456-3739
Provider Enumeration Date:
07/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MACALUSO-PEARE
Authorized Official First Name:
DEBBI
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
770-838-8554

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  035853 , 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: DA2102 . This is a "MEDICARE ID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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