Provider Demographics
NPI:1699868117
Name:GEORGIA REHABILITATION OUTREACH
Entity type:Organization
Organization Name:GEORGIA REHABILITATION OUTREACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-892-0998
Mailing Address - Street 1:1777 WASHINGTON ROAD
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344
Mailing Address - Country:US
Mailing Address - Phone:404-892-0998
Mailing Address - Fax:404-872-0095
Practice Address - Street 1:1777 WASHINGTON ROAD
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344
Practice Address - Country:US
Practice Address - Phone:404-892-0998
Practice Address - Fax:404-872-0095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1041C0700X1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00914394AMedicaid
GAGRP4847Medicare NSC