Basic Information
| Provider Information | |||||||||
| NPI: | 1487185492 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DONNEL CROSS HOST HOME | ||||||||
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| Mailing Information | |||||||||
| Address1: | 408 MACKENZIE CIR | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315331319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123315816 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1007 MARY ST | ||||||||
| Address2: | |||||||||
| City: | WAYCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315033823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124497100 | ||||||||
| FaxNumber: | 9124497063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2017 | ||||||||
| LastUpdateDate: | 03/22/2017 | ||||||||
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| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | GLYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9124497100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNISON BEHAVIORAL HEALTH | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320600000X | Y | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |
No ID Information.