Provider Demographics
NPI:1386718187
Name:SOUTH GEORGIA CSB
Entity type:Organization
Organization Name:SOUTH GEORGIA CSB
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-671-6101
Mailing Address - Street 1:1644 E PARK AVE
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-3413
Mailing Address - Country:US
Mailing Address - Phone:229-249-4900
Mailing Address - Fax:229-249-4910
Practice Address - Street 1:1644 E PARK AVE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-3413
Practice Address - Country:US
Practice Address - Phone:229-249-4900
Practice Address - Fax:229-249-4910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000607032XMedicaid
GA000607032VMedicaid