Healthcare Provider Details

I. General information

NPI: 1538609888
Provider Name (Legal Business Name): BEPROACTIVE FOUNDATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2017
Last Update Date: 03/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 WATER PL SE STE #220
ATLANTA GA
30339-7407
US

IV. Provider business mailing address

1830 WATER PL SE STE #220
ATLANTA GA
30339-7407
US

V. Phone/Fax

Practice location:
  • Phone: 770-319-7468
  • Fax: 866-416-1767
Mailing address:
  • Phone: 770-319-7468
  • Fax: 866-416-1767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateGA

VIII. Authorized Official

Name: MR. RJ LEWIS
Title or Position: EXECUTIVE DIRECTOR
Credential: M.A.
Phone: 770-319-7468