Basic Information
| Provider Information | |||||||||
| NPI: | 1407084387 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HIGHLAND RIVERS CENTER CSB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1620 HICKORY ST | ||||||||
| Address2: | SUITE 408 | ||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062705003 | ||||||||
| FaxNumber: | 7063707749 | ||||||||
| Practice Location | |||||||||
| Address1: | 1620 HICKORY ST | ||||||||
| Address2: | SUITE 408 | ||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062705003 | ||||||||
| FaxNumber: | 7063707749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2009 | ||||||||
| LastUpdateDate: | 06/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | AARON | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7062705000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HIGHLAND RIVERS CENTER CSB | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment |
ID Information
| ID | Type | State | Issuer | Description | 1447256243 | 01 | GA | ORGANIZATIONAL NPI NUMBER | OTHER | 000603468N | 05 | GA | MEDICAID |