MEDICARE: SOUTHERN WELLNESS SERVICES, 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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1841956364
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN WELLNESS SERVICES, LLC

Provider Business Mailing Address
First Line	:	3651 CANTON RD
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30066-7600
Country	:	US
Telephone Number	:	470-295-3152
Fax Number	:

Provider Business Practice Location Address
First Line	:	3651 CANTON RD
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30066-7600
Country	:	US
Telephone Number	:	470-295-3152
Fax Number	:	678-623-3318

Authorized Official
Title or Position	:	COO
Name	:	MR. FORREST RICHARDSON
Credential	:
Telephone Number	:	470-295-3152

Provider Enumeration Date	:	11/09/2021
Last Update Date	:	11/19/2021

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