MEDICARE: MCINTOSH TRAIL COMMUNITY SERVICE BOARD

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	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265610406
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCINTOSH TRAIL COMMUNITY SERVICE BOARD

Provider Business Mailing Address
First Line	:	1435 N EXPRESSWAY
Second Line	:	SUITE 301
City	:	GRIFFIN
State	:	GA
Zip	:	30223-9016
Country	:	US
Telephone Number	:	770-358-8250
Fax Number	:	770-229-3223

Provider Business Practice Location Address
First Line	:	463 ERNEST BILES DR
Second Line	:	SUITE B
City	:	JACKSON
State	:	GA
Zip	:	30233-2229
Country	:	US
Telephone Number	:	770-775-2676
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	SHARI THOMAS
Credential	:
Telephone Number	:	770-358-8254

Provider Enumeration Date	:	02/08/2008
Last Update Date	:	12/17/2015

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Directions to “MCINTOSH TRAIL COMMUNITY SERVICE BOARD ” Practice Location

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