=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215596911
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLARKE COUNTY DEPT OF FAMILY AND CHILDREN SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2019
-----------------------------------------------------
Last Update Date | 06/07/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 196 BEN BURTON CIR
-----------------------------------------------------
City | BOGART
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30622-1790
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-369-4030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 80586
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30608-0586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FISCAL OPERATIONS MANAGER
-----------------------------------------------------
Name | TERRY ANTWAN GARNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-369-4030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 347E00000X
-----------------------------------------------------
Taxonomy Name | Transportation Broker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------