MEDICARE: SOUTHERN LIVE OAK WELLNESS ACADEMY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	323P00000X	Psychiatric Residential Treatment Facility

General Provider Information

NPI Number	:	1295674141
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN LIVE OAK WELLNESS ACADEMY LLC

Provider Business Mailing Address
First Line	:	4609 N PEACHTREE RD
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30338-5810
Country	:	US
Telephone Number	:	404-951-6020
Fax Number	:

Provider Business Practice Location Address
First Line	:	4609 N PEACHTREE RD
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30338-5810
Country	:	US
Telephone Number	:	404-951-6020
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ELIZABETH KUECHER
Credential	:
Telephone Number	:	404-951-6020

Provider Enumeration Date	:	03/26/2026
Last Update Date	:	04/19/2026

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