MEDICARE: GEORGIA DEPT 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
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	005-01-026-9	GA

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	:	1912910936
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGIA DEPT OF HUMAN RESOURCES

Provider Business Mailing Address
First Line	:	647 SWINT AVE
Second Line	:
City	:	MILLEDGEVILLE
State	:	GA
Zip	:	31062-7525
Country	:	US
Telephone Number	:	478-445-8182
Fax Number	:

Provider Business Practice Location Address
First Line	:	170 WOODLAND CIR
Second Line	:	VARIOUS OTHER GROUP HOME ADDRESSES
City	:	MILLEDGEVILLE
State	:	GA
Zip	:	31061-2463
Country	:	US
Telephone Number	:	478-445-8182
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. GEORGE HARRIS
Credential	:
Telephone Number	:	478-445-8182

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	04/09/2009

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