Healthcare Provider Details

I. General information

NPI: 1396711099
Provider Name (Legal Business Name): CRISP REGIONAL HOSPITAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 09/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 BLACKSHEAR RD
CORDELE GA
31015
US

IV. Provider business mailing address

902 BLACKSHEAR RD
CORDELE GA
31015-3665
US

V. Phone/Fax

Practice location:
  • Phone: 229-271-9686
  • Fax: 229-271-9689
Mailing address:
  • Phone: 229-271-9686
  • Fax: 229-271-9689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number040446
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: LYNN RENEE BEARDEN
Title or Position: REVENUE INTEGRITY DIRECTOR
Credential:
Phone: 229-276-3146