Provider Demographics
NPI:1972085769
Name:RIVER EDGE BEHAVIORAL HEALTH CENTER
Entity type:Organization
Organization Name:RIVER EDGE BEHAVIORAL HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:OAKES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:478-803-7809
Mailing Address - Street 1:175 EMERY HWY
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-3692
Mailing Address - Country:US
Mailing Address - Phone:478-803-7700
Mailing Address - Fax:478-803-8598
Practice Address - Street 1:265 BOULEVARD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1208
Practice Address - Country:US
Practice Address - Phone:404-665-8550
Practice Address - Fax:404-665-8693
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVER EDGE BEHAVIORAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0104343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPHRE010434OtherGEORGIA PHARMACY LICENSE