Basic Information
| Provider Information | |||||||||
| NPI: | 1053589176 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDDLE FLINT COMMUNITY SERVICE BOARD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | MIDDLE FLINT BEHAVIORAL HEALTHCARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 N JACKSON ST | ||||||||
| Address2: | P.O. DRAWER 1348 | ||||||||
| City: | AMERICUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317093015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299312470 | ||||||||
| FaxNumber: | 2299312474 | ||||||||
| Practice Location | |||||||||
| Address1: | 1404 E UNION ST | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310927530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299312470 | ||||||||
| FaxNumber: | 2299312474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2008 | ||||||||
| LastUpdateDate: | 02/11/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | PAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2299312470 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MIDDLE FLINT AREA COMMUNITY BOARD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.