Healthcare Provider Details

I. General information

NPI: 1013044841
Provider Name (Legal Business Name): SOUTHWESTERN STATE HOSPITAL COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 08/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S PINETREE BLVD BUSINESS OFFICE - PATIENT BILLING DEPT
THOMASVILLE GA
31792-7128
US

IV. Provider business mailing address

PO BOX 1378 BUSINESS OFFICE - PATIENT BILLING DEPT
THOMASVILLE GA
31799-1378
US

V. Phone/Fax

Practice location:
  • Phone: 229-227-2977
  • Fax: 229-227-2955
Mailing address:
  • Phone: 229-227-2977
  • Fax: 229-227-2955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number581130678
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number581130678
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number581130678
License Number StateGA

VIII. Authorized Official

Name: MRS. HILARY J HOO-YOU
Title or Position: REGIONAL HOSPITAL ADMINISTRATOR
Credential:
Phone: 229-227-3020