Healthcare Provider Details

I. General information

NPI: 1508426453
Provider Name (Legal Business Name): GEORGIA DFCS REGION 12
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2019
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 SCRANTON RD
BRUNSWICK GA
31525-6601
US

IV. Provider business mailing address

PO BOX 580
BRUNSWICK GA
31521-0580
US

V. Phone/Fax

Practice location:
  • Phone: 912-554-3480
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State

VIII. Authorized Official

Name: KATHY HUNTER
Title or Position: FISCAL OPERATION MANAGER
Credential:
Phone: 912-554-3480