Cheaha Regional Mental Health Center, Inc.

Contacts

Phone	+1 256-245-1340
Fax	2562451343

Authorized person

Name	MS. SHEILA A. SUMMERS
Role	ELECTRONIC CLAIMS ADMINISTRATOR
Phone	2562451340

Taxonomy

Taxonomy Code	251B00000X - Case Management Agency
State	AL
Is Primary	No
Taxonomy Code	252Y00000X - Early Intervention Provider Agency
Is Primary	No
Taxonomy Code	261QM0801X - Mental Health Clinic/Center (Including Community Mental Health Center)
State	AL
Is Primary	Yes
Taxonomy Code	324500000X - Substance Abuse Rehabilitation Facility
State	AL
Is Primary	No

Other Provider Identifiers

Issuer	BCBS OF ALABAMA
Number	515 11684
State	AL
Issuer	BCBS OF ALABAMA
Number	510 08112
State	AL
Issuer	BCBS OF ALABAMA
Number	510 26112
State	AL
Issuer	BCBS OF ALABAMA
Number	510 79003
State	AL
Issuer	BCBS OF ALABAMA
Number	510 81173
State	AL

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1990-09-01
Business code	624100
Sponsor’s telephone number	2562451340
Plan sponsor’s address	351 W 3RD STREET, SYLACAUGA, AL, 35150

Signature of

Role	Plan administrator
Date	2017-07-25
Name of individual signing	MICHELE RYAN

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1990-09-01
Business code	624100
Sponsor’s telephone number	2562451340
Plan sponsor’s address	351 W 3RD STREET, SYLACAUGA, AL, 35150

Signature of

Role	Plan administrator
Date	2016-10-17
Name of individual signing	MICHELE RYAN

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1990-09-01
Business code	624100
Sponsor’s telephone number	2562451340
Plan sponsor’s address	351 W 3RD STREET, SYLACAUGA, AL, 35150

Signature of

Role	Plan administrator
Date	2015-07-24
Name of individual signing	MICHELE RYAN

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1990-09-01
Business code	624100
Sponsor’s telephone number	2562451340
Plan sponsor’s address	351 W 3RD STREET, SYLACAUGA, AL, 35150

Signature of

Role	Plan administrator
Date	2014-10-14
Name of individual signing	MICHELE RYAN

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1990-09-01
Business code	624100
Sponsor’s telephone number	2562451340
Plan sponsor’s address	351 W 3RD STREET, SYLACAUGA, AL, 35150

Signature of

Role	Plan administrator
Date	2014-10-14
Name of individual signing	MICHELE RYAN

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1990-09-01
Business code	624100
Sponsor’s telephone number	2562451340
Plan sponsor’s address	351 W 3RD STREET, SYLACAUGA, AL, 35150

Plan administrator’s name and address

Administrator’s EIN	630635955
Plan administrator’s name	CHEAHA REGIONAL MENTAL HEALTH CENTER
Plan administrator’s address	351 W 3RD STREET, SYLACAUGA, AL, 35150
Administrator’s telephone number	2562451340

Signature of

Role	Plan administrator
Date	2012-07-31
Name of individual signing	STEVE PERSONS

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1990-09-01
Business code	624100
Sponsor’s telephone number	2562451340
Plan sponsor’s address	351 W 3RD STREET, SYLACAUGA, AL, 35150

Plan administrator’s name and address

Administrator’s EIN	630635955
Plan administrator’s name	CHEAHA REGIONAL MENTAL HEALTH CENTER
Plan administrator’s address	351 W 3RD STREET, SYLACAUGA, AL, 35150
Administrator’s telephone number	2562451340

Signature of

Role	Plan administrator
Date	2011-10-14
Name of individual signing	CYNTHIA ATKINSON