1609276856 NPI number — GEORGIA DETOX AND RECOVERY, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609276856 NPI number — GEORGIA DETOX AND RECOVERY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA DETOX AND RECOVERY, 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:
1609276856
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2300 WINDY RIDGE PARKWAY
Provider Second Line Business Mailing Address:
SUITE 210S
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
470-440-1647
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1640 POWERS FERRY RD SE
Provider Second Line Business Practice Location Address:
BLDG 28, STE 100
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30067-5491
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-941-8993
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/25/2014

Additional Information

Authorized Official

Authorized Official Last Name:
TOWNSEND
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF REVENUE CYCLE
Authorized Official Telephone Number:
470-440-1647

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  033-251-D , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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