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NPI Code Detail

MEDICARE: GEORGIA DEPARTMENT OF HUMAN RESOURCES

MEDICARE: GEORGIA DEPARTMENT OF HUMAN RESOURCES
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
1320900000XIntellectual and/or Developmental Disabilities Community Based Residential Treatment FacilityGA

General Provider Information

NPI Number : 1316015308
Entity Type Code : Organization
Provider Name (Legal Business Name) : GEORGIA DEPARTMENT OF HUMAN RESOURCES
Provider Business Mailing Address
First Line : 100 MYRTLE BLVD
Second Line :
City : GRACEWOOD
State : GA
Zip : 30812-1500
Country : US
Telephone Number : 706-790-2030
Fax Number :
Provider Business Practice Location Address
First Line : 2577 LINCOLNTON PKWY
Second Line :
City : HEPHZIBAH
State : GA
Zip : 30815-5932
Country : US
Telephone Number : 706-790-2034
Fax Number :
Authorized Official
Title or Position : REGIONAL HOSPITAL ADMINISTRATOR
Name : DR. GAIL C JACKSON
Credential : M.D.
Telephone Number : 706-790-2030
Provider Enumeration Date : 11/30/2006
Last Update Date : 08/22/2020

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Directions to “GEORGIA DEPARTMENT OF HUMAN RESOURCES ” Practice Location

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