Healthcare Provider Details

I. General information

NPI: 1417940651
Provider Name (Legal Business Name): SOUTHWESTERN STATE HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 08/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 OLD ALBANY RD GATEWAY SUBSTANCE ABUSE DAY PROGRAM
THOMASVILLE GA
31792-3552
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 229-227-3004
  • Fax: 229-227-2663
Mailing address:
  • Phone: 229-227-3004
  • Fax: 229-227-2663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number58-1130678
License Number StateGA

VIII. Authorized Official

Name: MRS. HILARY J HOO-YOU
Title or Position: REGIONAL HOSPITAL ADMINISTRATOR
Credential:
Phone: 229-227-3021