MEDICARE: CSB OF EAST CENTRAL GA

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

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	:	1588995245
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CSB OF EAST CENTRAL GA

Provider Business Mailing Address
First Line	:	3421 MIKE PADGETT HWY
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30906-3815
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3294 SKINNER MILL RD
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-1918
Country	:	US
Telephone Number	:	706-432-4858
Fax Number	:	706-432-3780

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	WANDA JESSIE
Credential	:
Telephone Number	:	706-432-4858

Provider Enumeration Date	:	01/20/2010
Last Update Date	:	01/20/2010

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Directions to “CSB OF EAST CENTRAL GA ” Practice Location

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