1477134385 NPI number — THE RETREAT OF ATLANTA LLC

Table of content: (NPI 1477134385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477134385 NPI number — THE RETREAT OF ATLANTA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE RETREAT OF ATLANTA LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477134385
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 NW 17TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POMPANO BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33069-2814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-789-2161
Provider Business Mailing Address Fax Number:
954-764-6558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 GREENSBORO RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EATONTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31024-6042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-789-2161
Provider Business Practice Location Address Fax Number:
954-764-6558
Provider Enumeration Date:
04/21/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PEANA
Authorized Official First Name:
ANA
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
954-882-1332

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)