MEDICARE: CENTRAL CITY AIDS NETWORK, INC.

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	251V00000X	Voluntary or Charitable Agency	NONE NEEDED	GA

General Provider Information

NPI Number	:	1235230111
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL CITY AIDS NETWORK, INC.

Provider Business Mailing Address
First Line	:	2020 INGLESIDE AVE
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31204-2028
Country	:	US
Telephone Number	:	478-750-8080
Fax Number	:	478-750-1032

Provider Business Practice Location Address
First Line	:	2020 INGLESIDE AVE
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31204-2028
Country	:	US
Telephone Number	:	478-750-8080
Fax Number	:	478-750-1032

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. JOHNNY T FAMBRO
Credential	:	NON PROFIT AIDS SERV
Telephone Number	:	478-750-8080

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	08/22/2020

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