Provider Demographics
NPI:1447326541
Name:CSB OF EAST CENTRAL GEORGIA
Entity type:Organization
Organization Name:CSB OF EAST CENTRAL GEORGIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:JESSIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-432-4858
Mailing Address - Street 1:1720 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-5737
Mailing Address - Country:US
Mailing Address - Phone:706-736-4339
Mailing Address - Fax:706-432-3780
Practice Address - Street 1:1720 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-5737
Practice Address - Country:US
Practice Address - Phone:706-736-4339
Practice Address - Fax:706-432-3780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP 2010Medicare ID - Type Unspecified