=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447256243
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HIGHLAND RIVERS COMMUNITY SERVICE BOARD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2005
-----------------------------------------------------
Last Update Date | 11/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1503 N TIBBS RD
-----------------------------------------------------
City | DALTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30720-2915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-270-5000
-----------------------------------------------------
Fax | 706-270-5111
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1503 N TIBBS RD
-----------------------------------------------------
City | DALTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30720-2915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-270-5033
-----------------------------------------------------
Fax | 706-370-7749
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. MELANIE A. DALLAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-270-5000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------