Provider Demographics
NPI:1336430263
Name:NORTHEAST GEORGIA MENTAL HEALTH SERVICES, LLC
Entity type:Organization
Organization Name:NORTHEAST GEORGIA MENTAL HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANMEI
Authorized Official - Middle Name:
Authorized Official - Last Name:CAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-307-8053
Mailing Address - Street 1:1000 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:SUITE 6-186
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6737
Mailing Address - Country:US
Mailing Address - Phone:770-307-8053
Mailing Address - Fax:770-783-6334
Practice Address - Street 1:285 S PERRY ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4840
Practice Address - Country:US
Practice Address - Phone:770-307-8053
Practice Address - Fax:770-783-6334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA062482261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA863979251Medicaid