MEDICARE: GEORGIA PINES 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

General Provider Information

NPI Number	:	1841468097
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGIA PINES COMMUNITY SERVICE BOARD

Provider Business Mailing Address
First Line	:	1102 SMITH AVE
Second Line	:
City	:	THOMASVILLE
State	:	GA
Zip	:	31792-5739
Country	:	US
Telephone Number	:	229-225-4335
Fax Number	:	229-225-4374

Provider Business Practice Location Address
First Line	:	1641 N BROAD ST
Second Line	:
City	:	CAIRO
State	:	GA
Zip	:	39828-1160
Country	:	US
Telephone Number	:	229-225-4335
Fax Number	:	229-225-4374

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	ROBERT H JONES
Credential	:
Telephone Number	:	229-225-4373

Provider Enumeration Date	:	02/11/2008
Last Update Date	:	02/11/2008

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