MEDICARE: LOOKOUT MOUNTAIN COMMUNITY SERVICES

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

General Provider Information

NPI Number	:	1609041367
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOOKOUT MOUNTAIN COMMUNITY SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 1027
Second Line	:
City	:	LA FAYETTE
State	:	GA
Zip	:	30728-1027
Country	:	US
Telephone Number	:	706-638-5580
Fax Number	:	706-638-5445

Provider Business Practice Location Address
First Line	:	2933 LAKE HOWARD RD
Second Line	:
City	:	LA FAYETTE
State	:	GA
Zip	:	30728-6245
Country	:	US
Telephone Number	:	706-638-8758
Fax Number	:

Authorized Official
Title or Position	:	BILLING/ACCOUNT MANAGER
Name	:	DEBORAH FARRIS
Credential	:
Telephone Number	:	706-638-5580

Provider Enumeration Date	:	04/24/2008
Last Update Date	:	04/24/2008

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