Healthcare Provider Details

I. General information

NPI: 1497551337
Provider Name (Legal Business Name): KINGSTON WELLNESS RETREAT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2025
Last Update Date: 11/26/2025
Certification Date: 11/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 E HOWARD ST
KINGSTON GA
30145-3003
US

IV. Provider business mailing address

100 GOVERNORS TRCE STE 101
PEACHTREE CITY GA
30269-4853
US

V. Phone/Fax

Practice location:
  • Phone: 561-797-3264
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: DANIELLE CRAIG
Title or Position: VP FACILITY OPERATIONS
Credential:
Phone: 561-797-3264