MEDICARE: PEACH COUNTY ASSOCIATION FOR THE M.R. INC

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	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1992843346
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACH COUNTY ASSOCIATION FOR THE M.R. INC

Provider Business Mailing Address
First Line	:	213 ALLEN ST
Second Line	:
City	:	FORT VALLEY
State	:	GA
Zip	:	31030-2714
Country	:	US
Telephone Number	:	478-825-3124
Fax Number	:	478-825-8054

Provider Business Practice Location Address
First Line	:	213 ALLEN ST
Second Line	:
City	:	FORT VALLEY
State	:	GA
Zip	:	31030-2714
Country	:	US
Telephone Number	:	478-825-3124
Fax Number	:	478-825-8054

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. MICHAEL TODD YOUNGBLOOD
Credential	:
Telephone Number	:	478-825-3124

Provider Enumeration Date	:	02/01/2007
Last Update Date	:	08/22/2020

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