1912047572 NPI number — COBB COUNTY COMMUNITY SERVICES BOARD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912047572 NPI number — COBB COUNTY COMMUNITY SERVICES BOARD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COBB COUNTY COMMUNITY SERVICES 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:
1912047572
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3830 S COBB DR SE
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
SMYRNA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30080-5532
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-429-5000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5400 S COBB DR SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMYRNA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30080-7421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-794-4857
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CITRON
Authorized Official First Name:
TOD
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
770-429-5000

Provider Taxonomy Codes

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

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

  • Identifier: 621973741B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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