Organization
SAINT LAZARUS BEHAVIORAL HEALTH INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SAMUEL INIMBOM SAMUEL MD (PRESIDENT)
(865) 765-8224
Entity
Organization
Contact information
Practice address
4905 FORSYTH RD, MACON, GA 31210-4401
(865) 765-8224
(478) 474-6585
Mailing address
273 PROVIDENCE BLVD, MACON, GA 31210-7565
(865) 765-8224
(478) 474-6585
Taxonomy
Speciality
Code
Description
License number
State
261QM0850X
Adult Mental Health Clinic/Center
056360
GA
261QM0855X
Adolescent and Children Mental Health Clinic/Center
Primary
056360
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
712889273A
—
GA
Enumeration date
07/15/2009
Last updated
07/15/2009
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