Basic Information
| Provider Information | |||||||||
| NPI: | 1538442207 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HIGHLAND RIVERS COMMUNITY SERVICE BOARD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 APPLEWOOD DR | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062705002 | ||||||||
| FaxNumber: | 7062705111 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 WOODBINE AVE NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301652397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063140019 | ||||||||
| FaxNumber: | 7063140343 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2011 | ||||||||
| LastUpdateDate: | 04/03/2012 | ||||||||
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| AuthorizedOfficialLastName: | BEARDEN | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7062705000 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HIGHLAND RIVERS COMMUNITY SERVICE BOARD | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X | GA | N | Agencies | Day Training, Developmentally Disabled Services | 251S00000X | GA | N | Agencies | Community/Behavioral Health | 332BC3200X | GA | N | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment | 320800000X | GA | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 000601807AB | 05 | GA | MEDICAID |