Healthcare Provider Details

I. General information

NPI: 1871706382
Provider Name (Legal Business Name): SECOND NATURE BLUE RIDGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 05/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 FILE STREET
CLAYTON GA
30525-3023
US

IV. Provider business mailing address

236 FILE STREET
CLAYTON GA
30525-3023
US

V. Phone/Fax

Practice location:
  • Phone: 706-212-2037
  • Fax: 706-212-0354
Mailing address:
  • Phone: 706-212-2037
  • Fax: 706-212-0354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number50017
License Number StateGA

VIII. Authorized Official

Name: ANGIE EVANS
Title or Position: BUSINESS OFFICE
Credential:
Phone: 801-766-6604