NPIViewer - Provider NPI 1124085451

NPI:	1124085451
Name:	EASTER SEALS SOUTHERN GEORGIA INC.
Entity type:	Organization
Organization Name:	EASTER SEALS SOUTHERN GEORGIA INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:	COO
Authorized Official - Prefix:
Authorized Official - First Name:	MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:	HATCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:	229-439-7061
Mailing Address - Street 1:	1906 PALMYRA RD
Mailing Address - Street 2:
Mailing Address - City:	ALBANY
Mailing Address - State:	GA
Mailing Address - Zip Code:	31701-1575
Mailing Address - Country:	US
Mailing Address - Phone:	229-439-7061
Mailing Address - Fax:	229-439-2824
Practice Address - Street 1:	1906 PALMYRA RD
Practice Address - Street 2:
Practice Address - City:	ALBANY
Practice Address - State:	GA
Practice Address - Zip Code:	31701-1575
Practice Address - Country:	US
Practice Address - Phone:	229-439-7061
Practice Address - Fax:	229-439-2824
EIN:	<UNAVAIL>
Is Organization Subpart?:	No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:	2006-04-28
Last Update Date:	2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:

State	License ID	Taxonomies
GA	047-R-0011	251C00000X, 332B00000X, 320900000X
GA	047-R-011	385HR2060X

Primary?	Code	Type	Classification	Specialization
Yes	320900000X	Residential Treatment Facilities	Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No	251C00000X	Agencies	Day Training, Developmentally Disabled Services
No	332B00000X	Suppliers	Durable Medical Equipment & Medical Supplies
No	385HR2060X	Respite Care Facility	Respite Care	Respite Care, Intellectual and/or Developmental Disabilities, Child

State	Identifier ID	ID Type
GA	000551405AW	Medicaid
GA	000551405BG	Medicaid
GA	000551405BN	Medicaid
GA	000693844O	Medicaid
GA	000551405AZ	Medicaid
GA	000551405BA	Medicaid
GA	000551405BM	Medicaid
GA	000693844C	Medicaid
GA	000551405AK	Medicaid
GA	000551405AX	Medicaid
GA	000551405BB	Medicaid
GA	000551405BE	Medicaid
GA	000551405BL	Medicaid
GA	000551405BO	Medicaid
GA	000551405AY	Medicaid
GA	000693844N	Medicaid
GA	000693844W	Medicaid
GA	000551405BC	Medicaid
GA	000551405D	Medicaid
GA	000639844T	Medicaid
GA	000693844V	Medicaid
GA	000551405A	Medicaid
GA	000551405F	Medicaid
GA	000551405J	Medicaid
GA	000693844Q	Medicaid
GA	000551405BF	Medicaid
GA	000551405BH	Medicaid
GA	000693844S	Medicaid
GA	000693844X	Medicaid
GA	000520528A	Medicaid
GA	000551405AI	Medicaid
GA	000551405BI	Medicaid
GA	000693844B	Medicaid
GA	000639844T	Medicaid