Provider Demographics
NPI:1811436512
Name:CSB OF EAST CENTRAL GA
Entity type:Organization
Organization Name:CSB OF EAST CENTRAL GA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RESIDENTIAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:DUBOSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-432-4928
Mailing Address - Street 1:3421 MIKE PADGETT HWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-3815
Mailing Address - Country:US
Mailing Address - Phone:706-432-4928
Mailing Address - Fax:706-432-3861
Practice Address - Street 1:4008 RAMSWOOD DR
Practice Address - Street 2:
Practice Address - City:HEPHZIBAH
Practice Address - State:GA
Practice Address - Zip Code:30815-5849
Practice Address - Country:US
Practice Address - Phone:762-221-1090
Practice Address - Fax:706-432-3861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-15
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities