Healthcare Provider Details

I. General information

NPI: 1942374343
Provider Name (Legal Business Name): SOUTH GEORGIA CSB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 03/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 TIFTON ELDORADO ROAD
TIFTON GA
31794
US

IV. Provider business mailing address

340 TIFTON ELDORADO ROAD
TIFTON GA
31794
US

V. Phone/Fax

Practice location:
  • Phone: 229-391-2350
  • Fax: 229-386-7099
Mailing address:
  • Phone: 229-391-2350
  • Fax: 229-386-7099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. CHARLES R POWELL
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 229-671-6101