Healthcare Provider Details

I. General information

NPI: 1700245891
Provider Name (Legal Business Name): PERSONAL RECOVERY NETWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2016
Last Update Date: 08/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 CORPORATE CENTER CT
STOCKBRIDGE GA
30281-6388
US

IV. Provider business mailing address

250 CORPORATE CENTER CT
STOCKBRIDGE GA
30281-6388
US

V. Phone/Fax

Practice location:
  • Phone: 770-389-8100
  • Fax: 770-389-3030
Mailing address:
  • Phone: 770-389-8100
  • Fax: 770-389-3030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MISS ASHLEY NICHOLS TAGTACHIAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 770-548-2589