Basic Information
| Provider Information | |||||||||
| NPI: | 1689737033 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HIGHLAND RIVERS CSB | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HIGHLAND RIVERS POLK OP OFFICE AND CRISIS STABILIZATION PROGRAM | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 APPLEWOOD DRIVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062705002 | ||||||||
| FaxNumber: | 7063707749 | ||||||||
| Practice Location | |||||||||
| Address1: | 180 WATER OAK DR | ||||||||
| Address2: | |||||||||
| City: | CEDARTOWN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301252095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707482225 | ||||||||
| FaxNumber: | 7707490939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 09/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | BEARDEN | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7062705000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HIGHLAND RIVERS CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | GA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1447256243 | 01 | GA | ORGANIZATIONAL MASTER NPI | OTHER | 000759448J | 05 | GA | MEDICAID |