Basic Information
| Provider Information | |||||||||
| NPI: | 1497217715 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEACHTREE RECOVERY CENTERS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 70 GRUBER LN STE 107 | ||||||||
| Address2: | |||||||||
| City: | ST SIMONS ISLAND | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315222888 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3975 ROSWELL RD NE STE 104 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303424119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708072022 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2019 | ||||||||
| LastUpdateDate: | 04/04/2019 | ||||||||
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| AuthorizedOfficialLastName: | JENNINGS | ||||||||
| AuthorizedOfficialFirstName: | WENDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7708072022 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.