Healthcare Provider Details

I. General information

NPI: 1285663385
Provider Name (Legal Business Name): GEORGIA DEPARTMENT OF HUMAN RESOURCES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 09/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 NORTH DIVISION STREET NW BUILDING 103 - CLINICAL DIRECTOR'S OFFICE
ROME GA
30165-1454
US

IV. Provider business mailing address

705 NORTH DIVISION STREET NW BUILDING 103 - CLINICAL DIRECTOR'S OFFICE
ROME GA
30165-1454
US

V. Phone/Fax

Practice location:
  • Phone: 706-295-6285
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number057-013
License Number StateGA

VIII. Authorized Official

Name: THOMAS MULLER
Title or Position: CLINICAL DIRECTOR
Credential: M.D.
Phone: 706-295-6285