Basic Information
| Provider Information | |||||||||
| NPI: | 1881758613 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HIGHLAND RIVERS CENTER, CSB | ||||||||
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| OtherOrganizationName: | HIGHLAND RIVERS LIGHTHOUSE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 BURLEYSON DR | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062705002 | ||||||||
| FaxNumber: | 7063707749 | ||||||||
| Practice Location | |||||||||
| Address1: | 1705 DEAN AVE SE | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301617105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068025870 | ||||||||
| FaxNumber: | 7068020654 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WEAVER | ||||||||
| AuthorizedOfficialFirstName: | KLAY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7062705000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | ORGANIZATION MASTER NPI | OTHER |