Provider Demographics
NPI:1124253679
Name:LOGANVILLE COMMUNITY MINISTRY VILLAGE, INC.
Entity type:Organization
Organization Name:LOGANVILLE COMMUNITY MINISTRY VILLAGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHET
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:770-554-3599
Mailing Address - Street 1:678 TOM BREWER RD
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-4005
Mailing Address - Country:US
Mailing Address - Phone:770-554-3599
Mailing Address - Fax:770-554-3514
Practice Address - Street 1:678 TOM BREWER RD
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-4005
Practice Address - Country:US
Practice Address - Phone:770-554-3599
Practice Address - Fax:770-554-3514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005585251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health