1629359807 NPI number — MIR BEHAVIORAL HEALTH LLC

Table of content: (NPI 1629359807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629359807 NPI number — MIR BEHAVIORAL HEALTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIR BEHAVIORAL HEALTH LLC
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:
1629359807
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1227 ROCKBRIDGE RD
Provider Second Line Business Mailing Address:
STE 208-185
Provider Business Mailing Address City Name:
STONE MOUNTAIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30087-3064
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:
6886 MAIN ST
Provider Second Line Business Practice Location Address:
STE 215
Provider Business Practice Location Address City Name:
LITHONIA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30058-4508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-759-3444
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
RALSTON
Authorized Official First Name:
MADINAH
Authorized Official Middle Name:
I
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
770-759-3444

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY003079 , 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: 127231218G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com