MEDICARE: DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL DISABILITIES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility		GA

General Provider Information

NPI Number	:	1053547067
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL DISABILITIES

Provider Business Mailing Address
First Line	:	4916 LAPALOMA DR
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31907-2741
Country	:	US
Telephone Number	:	706-568-5118
Fax Number	:

Provider Business Practice Location Address
First Line	:	4916 LAPALOMA DR
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31907-2741
Country	:	US
Telephone Number	:	706-568-5118
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM DIRECTOR
Name	:	MR. RICK GARCIA
Credential	:
Telephone Number	:	706-568-5118

Provider Enumeration Date	:	06/04/2009
Last Update Date	:	06/21/2018

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