Healthcare Provider Details

I. General information

NPI: 1457454514
Provider Name (Legal Business Name): RIVER EDGE BEHAVIORAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 EMERY HWY
MACON GA
31217-3692
US

IV. Provider business mailing address

175 EMERY HWY
MACON GA
31217-3692
US

V. Phone/Fax

Practice location:
  • Phone: 478-803-7696
  • Fax: 478-746-5864
Mailing address:
  • Phone: 478-803-7696
  • Fax: 478-746-5864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE005543
License Number StateGA

VIII. Authorized Official

Name: BRYAN LAYMAN
Title or Position: PHCY DIRECTOR/PIC
Credential: RPH
Phone: 478-803-7650