MEDICARE: WOODSTOCK TREATMENT CENTER 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	261QM2800X	Methadone Clinic

General Provider Information

NPI Number	:	1508405150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WOODSTOCK TREATMENT CENTER LLC

Provider Business Mailing Address
First Line	:	403 MOUNT PARAN RD
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30327-3502
Country	:	US
Telephone Number	:	404-545-7279
Fax Number	:

Provider Business Practice Location Address
First Line	:	270 HERITAGE WALK
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30188-3875
Country	:	US
Telephone Number	:	678-494-5700
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	MS. NADINE MCDONALD
Credential	:
Telephone Number	:	678-367-9780

Provider Enumeration Date	:	12/30/2019
Last Update Date	:	02/12/2020

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