MEDICARE: ACWORTH OUTPATIENT DETOX, 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	261QR0800X	Recovery Care Clinic/Center
2	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1497327720
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACWORTH OUTPATIENT DETOX, LLC

Provider Business Mailing Address
First Line	:	6060 LAKE ACWORTH DR NW STE H
Second Line	:
City	:	ACWORTH
State	:	GA
Zip	:	30101-7358
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6060 LAKE ACWORTH DR NW STE H
Second Line	:
City	:	ACWORTH
State	:	GA
Zip	:	30101-7358
Country	:	US
Telephone Number	:	229-560-8634
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	JONATHAN DENKER
Credential	:
Telephone Number	:	229-560-8634

Provider Enumeration Date	:	07/15/2021
Last Update Date	:	06/24/2022

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