Healthcare Provider Details

I. General information

NPI: 1942730866
Provider Name (Legal Business Name): BIG HEART LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 04/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 KLONDIKE RD SW STE 403
CONYERS GA
30094-5173
US

IV. Provider business mailing address

1506 KLONDIKE RD SW STE 403
CONYERS GA
30094-5173
US

V. Phone/Fax

Practice location:
  • Phone: 404-333-7725
  • Fax:
Mailing address:
  • Phone: 770-285-6699
  • Fax: 770-285-6510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TURQUOISE ALLEN
Title or Position: CEO
Credential:
Phone: 770-285-6699