Healthcare Provider Details

I. General information

NPI: 1780814574
Provider Name (Legal Business Name): SAINT LAZARUS BEHAVIORAL HEALTH INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 07/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4905 FORSYTH RD
MACON GA
31210-4401
US

IV. Provider business mailing address

273 PROVIDENCE BLVD
MACON GA
31210-7565
US

V. Phone/Fax

Practice location:
  • Phone: 865-765-8224
  • Fax: 478-474-6585
Mailing address:
  • Phone: 865-765-8224
  • Fax: 478-474-6585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number056360
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number056360
License Number StateGA

VIII. Authorized Official

Name: DR. SAMUEL INIMBOM SAMUEL
Title or Position: PRESIDENT
Credential: MD
Phone: 865-765-8224