MEDICARE: GEORGIA MOUNTAIN COMMUNITY SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000607054BZ	OTHER	GA	RESIDENTIAL HOME

General Provider Information

NPI Number	:	1164787743
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGIA MOUNTAIN COMMUNITY SERVICES

Provider Business Mailing Address
First Line	:	4331 THURMOND TANNER PARKWAY
Second Line	:
City	:	FLOWERY BRANCH
State	:	GA
Zip	:	30542-2829
Country	:	US
Telephone Number	:	678-513-5720
Fax Number	:	678-513-5836

Provider Business Practice Location Address
First Line	:	2520 W DENNIS DR
Second Line	:
City	:	GAINESVILLE
State	:	GA
Zip	:	30507-7495
Country	:	US
Telephone Number	:	678-513-5720
Fax Number	:	678-513-5836

Authorized Official
Title or Position	:	BILLING SPECIALIST
Name	:	TAMMY THOMPSON
Credential	:
Telephone Number	:	678-513-5720

Provider Enumeration Date	:	07/10/2012
Last Update Date	:	07/10/2012

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