Healthcare Provider Details

I. General information

NPI: 1346319142
Provider Name (Legal Business Name): DEVEREUX FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 01/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1291 STANLEY RD NW
KENNESAW GA
30152-4359
US

IV. Provider business mailing address

1283 KENNESTONE CIR SUITE 100
MARIETTA GA
30066-6029
US

V. Phone/Fax

Practice location:
  • Phone: 770-427-0147
  • Fax:
Mailing address:
  • Phone: 770-427-0147
  • Fax: 770-423-1502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number5910
License Number StateGA

VIII. Authorized Official

Name: MR. MARIO BOLIVAR JR.
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 687-303-2669