Basic Information
| Provider Information | |||||||||
| NPI: | 1104179001 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HIGHLAND RIVERS COMMUNITY SERVICE BOARD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 APPLEWOOD DR STE 1 | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062705033 | ||||||||
| FaxNumber: | 7063707749 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 EAST 10TH STREET | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301616164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062705033 | ||||||||
| FaxNumber: | 7063707749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2012 | ||||||||
| LastUpdateDate: | 10/17/2012 | ||||||||
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| AuthorizedOfficialLastName: | WHITLOW | ||||||||
| AuthorizedOfficialFirstName: | ROBIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7062705033 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 000936559GW | 05 | GA | MEDICAID |