Healthcare Provider Details

I. General information

NPI: 1427416577
Provider Name (Legal Business Name): LIFE REDISCOVERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2016
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 UPPER RIVERDALE RD SW
RIVERDALE GA
30274-2540
US

IV. Provider business mailing address

113 UPPER RIVERDALE RD SW
RIVERDALE GA
30274-2540
US

V. Phone/Fax

Practice location:
  • Phone: 678-545-6768
  • Fax: 678-528-9489
Mailing address:
  • Phone: 678-545-6768
  • Fax: 678-528-9489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: FELICIA WATTS
Title or Position: CEO
Credential:
Phone: 678-545-6768