Healthcare Provider Details

I. General information

NPI: 1275686198
Provider Name (Legal Business Name): GA. MTNS COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2318 BROWNS BRIDGE RD
GAINESVILLE GA
30504-6041
US

IV. Provider business mailing address

2315 STEPHENS CIR
GAINESVILLE GA
30506-1115
US

V. Phone/Fax

Practice location:
  • Phone: 678-207-1663
  • Fax: 678-207-1620
Mailing address:
  • Phone: 770-536-4959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number0591
License Number StateGA

VIII. Authorized Official

Name: DR. JON C. RUBENOW
Title or Position: MEDICAL DIRECTOR
Credential: D.O.
Phone: 678-513-5707