Provider Demographics
NPI:1023516002
Name:COMMUNITY SERVICE BOARD OF EAST CENTRAL GEORGIA
Entity type:Organization
Organization Name:COMMUNITY SERVICE BOARD OF EAST CENTRAL GEORGIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-432-4837
Mailing Address - Street 1:3421 MIKE PADGETT HWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-3815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:355 BOBWHITE TRL
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-5886
Practice Address - Country:US
Practice Address - Phone:706-432-4837
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY SERVICE BOARD OF EAST CENTRAL GEORGIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000605833YMedicaid