Provider Demographics
NPI:1164900858
Name:INFINITY SERVICES GROUP, LLC
Entity type:Organization
Organization Name:INFINITY SERVICES GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUBRICCA
Authorized Official - Middle Name:THJUANA
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:229-669-2080
Mailing Address - Street 1:4326 BRADDOCK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-5422
Mailing Address - Country:US
Mailing Address - Phone:229-669-2080
Mailing Address - Fax:
Practice Address - Street 1:3601 HILTON AVE STE 225
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-7373
Practice Address - Country:US
Practice Address - Phone:229-669-2080
Practice Address - Fax:706-608-8345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003199361AMedicaid