Healthcare Provider Details

I. General information

NPI: 1023204864
Provider Name (Legal Business Name): RIVER EDGE BEHAVIORAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2007
Last Update Date: 09/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

952 MAIN ST
JEFFERSONVILLE GA
31044-3727
US

IV. Provider business mailing address

175 EMERY HWY
MACON GA
31217-3692
US

V. Phone/Fax

Practice location:
  • Phone: 478-751-4507
  • Fax:
Mailing address:
  • Phone: 478-751-4507
  • 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: MRS. EMILY BETH TYLER
Title or Position: CFO
Credential:
Phone: 478-752-3231