Provider Demographics
NPI:1851811210
Name:COMMUNITY SERVICE BOARD OF MIDDLE GEORGIA
Entity type:Organization
Organization Name:COMMUNITY SERVICE BOARD OF MIDDLE GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-275-6811
Mailing Address - Street 1:223 N ANDERSON DR
Mailing Address - Street 2:
Mailing Address - City:SWAINSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30401-4440
Mailing Address - Country:US
Mailing Address - Phone:478-289-2683
Mailing Address - Fax:478-289-2798
Practice Address - Street 1:1114 CLARKS MILL RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:GA
Practice Address - Zip Code:30434-5304
Practice Address - Country:US
Practice Address - Phone:478-625-7214
Practice Address - Fax:478-625-7240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-26
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000709288FMedicaid