Healthcare Provider Details

I. General information

NPI: 1891869020
Provider Name (Legal Business Name): LOOKOUT MOUNTAIN COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 HIGHWAY 48
SUMMERVILLE GA
30747-1506
US

IV. Provider business mailing address

PO BOX 1027
LA FAYETTE GA
30728-1027
US

V. Phone/Fax

Practice location:
  • Phone: 706-857-5465
  • Fax: 706-857-0934
Mailing address:
  • Phone: 706-638-5584
  • Fax: 706-638-5585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: THOMAS W. FORD
Title or Position: EXECUTIVE DIRECTOR
Credential: PH.D.
Phone: 706-638-5584