Healthcare Provider Details

I. General information

NPI: 1801235312
Provider Name (Legal Business Name): PAUL ANDERSON YOUTH HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1603 MCINTOSH STREET
VIDALIA GA
30474
US

IV. Provider business mailing address

PO BOX 525
VIDALIA GA
30475-0525
US

V. Phone/Fax

Practice location:
  • Phone: 912-537-7237
  • Fax: 912-537-8734
Mailing address:
  • Phone: 912-537-7237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: BETTY C. BURRIS
Title or Position: PROGRAM DIRECTOR
Credential: MA
Phone: 912-537-7237