Healthcare Provider Details

I. General information

NPI: 1043631476
Provider Name (Legal Business Name): HEALTHQWEST FRONTIERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2014
Last Update Date: 03/04/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 NORTHWOODS PLAZA
MACON GA
31204-1441
US

IV. Provider business mailing address

1317 ROUTE 73 STE 200
MOUNT LAUREL NJ
08054-2202
US

V. Phone/Fax

Practice location:
  • Phone: 478-330-7164
  • Fax:
Mailing address:
  • Phone: 856-439-6111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License NumberNTP001074
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBYN TANIS
Title or Position: EXECUTIVE DIRECTOR OF CONTRACT MGMT
Credential:
Phone: 856-533-8762