Provider Demographics
NPI:1124295571
Name:MCINTOSH TRAIL CSB
Entity type:Organization
Organization Name:MCINTOSH TRAIL CSB
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SHARI
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-358-8254
Mailing Address - Street 1:1435 N EXPRESSWAY
Mailing Address - Street 2:SUITE 301
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-9016
Mailing Address - Country:US
Mailing Address - Phone:770-358-8250
Mailing Address - Fax:770-229-3223
Practice Address - Street 1:133 FORSYTH ST
Practice Address - Street 2:
Practice Address - City:BARNESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30204-1470
Practice Address - Country:US
Practice Address - Phone:770-358-5252
Practice Address - Fax:770-229-3223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000601609AHMedicaid
GA000601609AHMedicaid