Provider Demographics
NPI:1386009520
Name:GEORGIA DETOX AND RECOVERY, LLC
Entity type:Organization
Organization Name:GEORGIA DETOX AND RECOVERY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF RCM
Authorized Official - Prefix:
Authorized Official - First Name:TYEAST
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-813-0428
Mailing Address - Street 1:2300 WINDY RIDGE PARKWAY
Mailing Address - Street 2:SUITE 210S
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339
Mailing Address - Country:US
Mailing Address - Phone:470-440-1647
Mailing Address - Fax:
Practice Address - Street 1:2812 HILLCREEK DR STE B
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-5632
Practice Address - Country:US
Practice Address - Phone:844-242-0806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVERMEND HEALH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-15
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA121-253-D261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder