Basic Information
Provider Information | |||||||||
NPI: | 1043373467 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HIGHLAND RIVERS CSB | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HIGHLAND RIVERS CHEROKEE OFFICE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1401 APPLEWOOD DRIVE | ||||||||
Address2: | SUITE 1 | ||||||||
City: | DALTON | ||||||||
State: | GA | ||||||||
PostalCode: | 307202699 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7062705002 | ||||||||
FaxNumber: | 7063707749 | ||||||||
Practice Location | |||||||||
Address1: | 191 LAMAR HALEY DR | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | GA | ||||||||
PostalCode: | 301148019 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7707041600 | ||||||||
FaxNumber: | 7707041610 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/18/2006 | ||||||||
LastUpdateDate: | 09/20/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BEARDEN | ||||||||
AuthorizedOfficialFirstName: | JASON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 7062705000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | HIGHLAND RIVERS CENTER, CSB | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   | GA | N |   | Agencies | Community/Behavioral Health |   | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 000601807B | 05 | GA |   | MEDICAID | 1447256243 | 01 | GA | ORGANIZATION MASTER NPI | OTHER |