Provider Demographics
NPI:1538442207
Name:HIGHLAND RIVERS COMMUNITY SERVICE BOARD
Entity type:Organization
Organization Name:HIGHLAND RIVERS COMMUNITY SERVICE BOARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BEARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-270-5000
Mailing Address - Street 1:1401 APPLEWOOD DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2699
Mailing Address - Country:US
Mailing Address - Phone:706-270-5002
Mailing Address - Fax:706-270-5111
Practice Address - Street 1:1 WOODBINE AVE NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-2397
Practice Address - Country:US
Practice Address - Phone:706-314-0019
Practice Address - Fax:706-314-0343
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HIGHLAND RIVERS COMMUNITY SERVICE BOARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-20
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251C00000X, 251S00000X, 332BC3200X, 320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000601807ABMedicaid