Healthcare Provider Details

I. General information

NPI: 1689657637
Provider Name (Legal Business Name): COMMUNITY SERVICE BOARD OF MIDDLE GEORGIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121A BELLEVUE RD
DUBLIN GA
31021-2998
US

IV. Provider business mailing address

2121A BELLEVUE RD
DUBLIN GA
31021-2998
US

V. Phone/Fax

Practice location:
  • Phone: 478-272-1190
  • Fax: 478-274-7628
Mailing address:
  • Phone: 478-272-1190
  • Fax: 478-274-7628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number007-R-0003
License Number StateGA

VIII. Authorized Official

Name: MR. KEITH MORAN
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 478-272-1190