Healthcare Provider Details

I. General information

NPI: 1508010711
Provider Name (Legal Business Name): LOOKOUT MOUNTAIN COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2008
Last Update Date: 11/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 LAKE SHORE DR
CHATSWORTH GA
30705-2861
US

IV. Provider business mailing address

PO BOX 1027
LA FAYETTE GA
30728-1027
US

V. Phone/Fax

Practice location:
  • Phone: 706-581-7907
  • Fax:
Mailing address:
  • Phone: 706-638-5580
  • Fax: 706-638-5585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DEBORAH FARRIS
Title or Position: AR MANAGER
Credential:
Phone: 706-638-5580