Healthcare Provider Details

I. General information

NPI: 1578636817
Provider Name (Legal Business Name): SOUTH GEORGIA CSB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 WILLOW WOOD GATE
VALDOSTA GA
31602-6709
US

IV. Provider business mailing address

4401 WILLOW WOOD GATE
VALDOSTA GA
31602-6709
US

V. Phone/Fax

Practice location:
  • Phone: 229-242-4734
  • Fax: 229-242-2984
Mailing address:
  • Phone: 229-242-4734
  • Fax: 229-242-2984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. SUE GUPTON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 229-245-2379