Healthcare Provider Details

I. General information

NPI: 1457402596
Provider Name (Legal Business Name): GRN COMMUNITY SERVICE BOARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 STAR CREST DRIVE
CONYERS GA
30012-6315
US

IV. Provider business mailing address

6203 NIXON CIR NE
COVINGTON GA
30014-6315
US

V. Phone/Fax

Practice location:
  • Phone: 770-785-5910
  • Fax:
Mailing address:
  • Phone: 678-342-0814
  • Fax:

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: MICHELE LEA BAGBY
Title or Position: FAIMLY ADVOCATE
Credential:
Phone: 770-785-5910