Healthcare Provider Details

I. General information

NPI: 1538336524
Provider Name (Legal Business Name): GWINNETT, ROCKDALE & NEWTON COMMUNITY SERVICE BOARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 05/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 OLD NORCROSS RD STE C
LAWRENCEVILLE GA
30045-7667
US

IV. Provider business mailing address

595 OLD NORCROSS RD STE C
LAWRENCEVILLE GA
30045-7667
US

V. Phone/Fax

Practice location:
  • Phone: 770-995-6902
  • Fax:
Mailing address:
  • Phone: 770-995-6902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: MS. LISA JO CALANDRINO
Title or Position: DAY SERVICES COORDINATOR
Credential: M.S. M.H.P. CPRP
Phone: 770-995-6902