Basic Information
| Provider Information | |||||||||
| NPI: | 1336437763 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HIGHLAND RIVERS CENTER, CSB | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ROME CRISIS UNIT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1620 HICKORY ST | ||||||||
| Address2: | STE 406 | ||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062705002 | ||||||||
| FaxNumber: | 7062705111 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 WOODBINE AVE NW | ||||||||
| Address2: | NW | ||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301652397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063140019 | ||||||||
| FaxNumber: | 7063140343 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2011 | ||||||||
| LastUpdateDate: | 07/19/2011 | ||||||||
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| AuthorizedOfficialLastName: | CROSBY | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7062705002 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HIGHLAND RIVERS CENTER, CSB | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.