Healthcare Provider Details

I. General information

NPI: 1265092654
Provider Name (Legal Business Name): CALVARY HEALTHCARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 VAN DELL DR
ROCK SPRING GA
30739-2640
US

IV. Provider business mailing address

256 VAN DELL DR
ROCK SPRING GA
30739-2640
US

V. Phone/Fax

Practice location:
  • Phone: 478-230-9067
  • Fax:
Mailing address:
  • Phone: 478-230-9067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MATTHEW MCUMBER
Title or Position: OWNER
Credential: LCSW
Phone: 478-230-9067