Healthcare Provider Details

I. General information

NPI: 1427562750
Provider Name (Legal Business Name): SECOND NATURE BLUE RIDGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2017
Last Update Date: 11/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 FILE ST.
CLAYTON GA
30525
US

IV. Provider business mailing address

PO BOX 809
CLAYTON GA
30525
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 Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number50017-RCC
License Number StateGA

VIII. Authorized Official

Name: VANESSA ALLEN
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 706-212-2037