Healthcare Provider Details

I. General information

NPI: 1467647875
Provider Name (Legal Business Name): MENTAL RETARDATION WAIVER PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2007
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 CLABORN ST.
CUTHBERT GA
39840
US

IV. Provider business mailing address

2100 COMER AVE
COLUMBUS GA
31904-8725
US

V. Phone/Fax

Practice location:
  • Phone: 706-596-5583
  • Fax:
Mailing address:
  • Phone: 706-321-9606
  • Fax: 706-322-6576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: PERRY ALEXANDER
Title or Position: CEO
Credential:
Phone: 706-596-5582