Healthcare Provider Details

I. General information

NPI: 1497327720
Provider Name (Legal Business Name): ACWORTH OUTPATIENT DETOX, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6060 LAKE ACWORTH DR NW STE H
ACWORTH GA
30101-7358
US

IV. Provider business mailing address

6060 LAKE ACWORTH DR NW STE H
ACWORTH GA
30101-7358
US

V. Phone/Fax

Practice location:
  • Phone: 229-560-8634
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN DENKER
Title or Position: MEMBER
Credential:
Phone: 229-560-8634