Healthcare Provider Details

I. General information

NPI: 1184950917
Provider Name (Legal Business Name): KLJ COMMUNITY SERVICE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2009
Last Update Date: 03/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2459 WISE ST
COLUMBUS GA
31903-3453
US

IV. Provider business mailing address

2459 WISE ST
COLUMBUS GA
31903-3453
US

V. Phone/Fax

Practice location:
  • Phone: 770-468-0476
  • Fax:
Mailing address:
  • Phone: 770-468-0476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. BETTY MARTIN-WOODS
Title or Position: CEO
Credential:
Phone: 770-468-0476