MEDICARE: LOOKOUT MOUNTAIN COMMUNITY SEVICES

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	044472	GA

General Provider Information

NPI Number	:	1356405773
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOOKOUT MOUNTAIN COMMUNITY SEVICES

Provider Business Mailing Address
First Line	:	2921 MITCHELL CV NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30319-2695
Country	:	US
Telephone Number	:	404-467-7670
Fax Number	:	706-639-2055

Provider Business Practice Location Address
First Line	:	2921 MITCHELL CV NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30319-2695
Country	:	US
Telephone Number	:	404-467-7670
Fax Number	:	706-639-2055

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	RJICHARD EDWARD GRANT
Credential	:	M.D.
Telephone Number	:	404-467-7670

Provider Enumeration Date	:	12/20/2006
Last Update Date	:	08/22/2020

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