1801235312 NPI number — PAUL ANDERSON YOUTH HOME, INC.

Table of content: DR. ERICKA JUSTINE DIGIOIA PHARM. D, RPH (NPI 1326362914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801235312 NPI number — PAUL ANDERSON YOUTH HOME, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAUL ANDERSON YOUTH HOME, 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:
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:
1801235312
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 525
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIDALIA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30475-0525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-537-7237
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1603 MCINTOSH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIDALIA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30474
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-537-7237
Provider Business Practice Location Address Fax Number:
912-537-8734
Provider Enumeration Date:
06/18/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BURRIS
Authorized Official First Name:
BETTY
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
PROGRAM DIRECTOR
Authorized Official Telephone Number:
912-537-7237

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 322D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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