Provider Demographics
NPI:1407929730
Name:SOUTH GEORGIA CSB
Entity type:Organization
Organization Name:SOUTH GEORGIA CSB
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-671-6140
Mailing Address - Street 1:252 N SAINT AUGUSTINE RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-5274
Mailing Address - Country:US
Mailing Address - Phone:229-245-6400
Mailing Address - Fax:229-249-4996
Practice Address - Street 1:252 N SAINT AUGUSTINE RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-5274
Practice Address - Country:US
Practice Address - Phone:229-245-6400
Practice Address - Fax:229-249-4996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0000742475OMedicaid
GAGRP2255Medicare ID - Type Unspecified