Healthcare Provider Details

I. General information

NPI: 1790782431
Provider Name (Legal Business Name): LOOKOUT MOUNTAIN COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MIZE ST.
LAFAYETTE GA
30728
US

IV. Provider business mailing address

501 MIZE ST.
LAFAYETTE GA
30728
US

V. Phone/Fax

Practice location:
  • Phone: 706-638-5580
  • Fax: 706-638-5445
Mailing address:
  • Phone: 706-638-5580
  • Fax: 706-638-5445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS FORD
Title or Position: CEO
Credential: PH D
Phone: 706-638-5580