Provider Demographics
NPI:1154935450
Name:EDLYN LLC
Entity type:Organization
Organization Name:EDLYN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:T
Authorized Official - Last Name:GRIMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-540-9963
Mailing Address - Street 1:3267 WATSON MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-8297
Mailing Address - Country:US
Mailing Address - Phone:718-747-9494
Mailing Address - Fax:
Practice Address - Street 1:1880 BRASELTON HWY # 118-5174
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-2852
Practice Address - Country:US
Practice Address - Phone:470-460-5568
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-03
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty