Basic Information
| Provider Information | |||||||||
| NPI: | 1689707150 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY SERVICE BOARD OF MIDDLE GEORGIA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOPERTON C&A DAY SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2121A BELLEVUE RD | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310212998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782721190 | ||||||||
| FaxNumber: | 4782747628 | ||||||||
| Practice Location | |||||||||
| Address1: | 417 LOUISIANA AVE E | ||||||||
| Address2: | |||||||||
| City: | SOPERTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304571126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782721190 | ||||||||
| FaxNumber: | 4782747628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 07/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | REID | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4782721190 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 000606284M | 05 | GA | MEDICAID |