Healthcare Provider Details

I. General information

NPI: 1164995965
Provider Name (Legal Business Name): COMMUNITY SERVICE BOARD OF EAST CENTRAL GEORGIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2019
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1908 DRIFTWOOD DR
AUGUSTA GA
30909-4113
US

IV. Provider business mailing address

3421 MIKE PADGETT HWY
AUGUSTA GA
30906-3815
US

V. Phone/Fax

Practice location:
  • Phone: 706-432-4837
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MICHELE PRIOR
Title or Position: BILLING MANAGER
Credential:
Phone: 706-432-4837