Provider Demographics
NPI:1194938696
Name:THOMAS GRADY SERVICE CENTER
Entity type:Organization
Organization Name:THOMAS GRADY SERVICE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-225-4065
Mailing Address - Street 1:106 PLANTATION OAK DR
Mailing Address - Street 2:PO BOX 2507
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-3500
Mailing Address - Country:US
Mailing Address - Phone:229-225-4065
Mailing Address - Fax:229-225-5027
Practice Address - Street 1:106 PLANTATION OAK DR
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-3500
Practice Address - Country:US
Practice Address - Phone:229-225-4065
Practice Address - Fax:229-225-5027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00669413AMedicaid