Basic Information
| Provider Information | |||||||||
| NPI: | 1801332150 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVERMEND HEALTH CENTERS, LLC OF GEORGIA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2300 WINDY RIDGE PKWY SE | ||||||||
| Address2: | SUIET 210S | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303395665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788130505 | ||||||||
| FaxNumber: | 6788130505 | ||||||||
| Practice Location | |||||||||
| Address1: | 1640 POWERS FERRY RD SE | ||||||||
| Address2: | BUILDING 6, SUIET 100 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300675491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788130505 | ||||||||
| FaxNumber: | 6788130505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2017 | ||||||||
| LastUpdateDate: | 04/11/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REYNOLDS | ||||||||
| AuthorizedOfficialFirstName: | TYEAST | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF RCM | ||||||||
| AuthorizedOfficialTelephone: | 6788130428 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RIVERMEND HEALTH, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 033-421-D | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.