Healthcare Provider Details

I. General information

NPI: 1912910936
Provider Name (Legal Business Name): GEORGIA DEPT OF HUMAN RESOURCES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 04/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 WOODLAND CIR VARIOUS OTHER GROUP HOME ADDRESSES
MILLEDGEVILLE GA
31061-2463
US

IV. Provider business mailing address

647 SWINT AVE
MILLEDGEVILLE GA
31062-7525
US

V. Phone/Fax

Practice location:
  • Phone: 478-445-8182
  • Fax:
Mailing address:
  • Phone: 478-445-8182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number005-01-026-9
License Number StateGA

VIII. Authorized Official

Name: MR. GEORGE HARRIS
Title or Position: DIRECTOR
Credential:
Phone: 478-445-8182