1790782431 NPI number — LOOKOUT MOUNTAIN COMMUNITY SERVICES

Table of content: (NPI 1790782431)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790782431 NPI number — LOOKOUT MOUNTAIN COMMUNITY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOOKOUT MOUNTAIN COMMUNITY SERVICES
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:
1790782431
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 MIZE ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-638-5580
Provider Business Mailing Address Fax Number:
706-638-5445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 MIZE ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-638-5580
Provider Business Practice Location Address Fax Number:
706-638-5445
Provider Enumeration Date:
07/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
FORD
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
706-638-5580

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • 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: 00604513E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00604513G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0604513U , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00604513H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00604513Z , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00604513C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00810059A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00604513B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00604513D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00810059G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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