Healthcare Provider Details

I. General information

NPI: 1215064332
Provider Name (Legal Business Name): TWIN CEDARS YOUTH SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1022 E DEPOT ST
LAGRANGE GA
30241-3412
US

IV. Provider business mailing address

310 N LEWIS ST P.O. BOX 1526
LAGRANGE GA
30240-2740
US

V. Phone/Fax

Practice location:
  • Phone: 706-884-1717
  • Fax: 706-884-8321
Mailing address:
  • Phone: 706-298-0050
  • Fax: 706-298-0055

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 Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number StateGA

VIII. Authorized Official

Name: MR. MICHAEL J. ANGSTADT
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 706-298-0050