Healthcare Provider Details

I. General information

NPI: 1033630355
Provider Name (Legal Business Name): COMMUNITY SERVICE BOARD OF MIDDLE GEORGIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2017
Last Update Date: 06/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

762 OLD MILLEN HWY
WAYNESBORO GA
30830-8808
US

IV. Provider business mailing address

223 N ANDERSON DR
SWAINSBORO GA
30401-4440
US

V. Phone/Fax

Practice location:
  • Phone: 706-437-6854
  • Fax: 706-437-6851
Mailing address:
  • Phone: 478-289-2683
  • Fax: 478-289-2798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KEITH MORAN
Title or Position: CFO
Credential:
Phone: 478-275-6811