Provider Demographics
NPI:1346743481
Name:SUGAR GROVE MBH-GA, LLC
Entity type:Organization
Organization Name:SUGAR GROVE MBH-GA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERSILY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-348-1421
Mailing Address - Street 1:PO BOX 4107
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25364-4107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:133 HEDRICK DR
Practice Address - Street 2:
Practice Address - City:SUGAR GROVE
Practice Address - State:WV
Practice Address - Zip Code:26815-5068
Practice Address - Country:US
Practice Address - Phone:304-348-1079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility