Healthcare Provider Details

I. General information

NPI: 1265216683
Provider Name (Legal Business Name): EDGE TREATMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 10/21/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11205 ALPHARETTA HWY STE H4
ROSWELL GA
30076-5649
US

IV. Provider business mailing address

11205 ALPHARETTA HWY STE H4
ROSWELL GA
30076-5649
US

V. Phone/Fax

Practice location:
  • Phone: 706-342-6024
  • 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 Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA JARVIS
Title or Position: CEO
Credential:
Phone: 706-342-6024