Healthcare Provider Details

I. General information

NPI: 1245541192
Provider Name (Legal Business Name): GEORGIA MOUNTAINS COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 FERNSIDE DR
TOCCOA GA
30577-8942
US

IV. Provider business mailing address

4331 THURMON TANNER RD
FLOWERY BRANCH GA
30542-2829
US

V. Phone/Fax

Practice location:
  • Phone: 706-886-6521
  • Fax: 678-513-5836
Mailing address:
  • Phone: 678-513-5733
  • Fax: 678-513-5836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000666553E
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: KAREN R TUCKER
Title or Position: BILLING MANAGER
Credential:
Phone: 678-513-5733