Basic Information
| Provider Information | |||||||||
| NPI: | 1306983051 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PARKWOOD DEVELOPMENTAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 N LEE ST | ||||||||
| Address2: | |||||||||
| City: | VALDOSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 316023309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292426268 | ||||||||
| FaxNumber: | 2292425845 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 N LEE ST | ||||||||
| Address2: | |||||||||
| City: | VALDOSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 316023309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292426268 | ||||||||
| FaxNumber: | 2292425845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | TEMPLETON | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2292426268 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | NHA000205 | GA | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
No ID Information.