Healthcare Provider Details

I. General information

NPI: 1821393380
Provider Name (Legal Business Name): TIFTON ADDICTION ASSOCIATES, LLC. D/B/A TLC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2011
Last Update Date: 01/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 NORTH TIFT AVE SUITE 202
TIFTON GA
31794
US

IV. Provider business mailing address

2402 TIFT AVE N STE 202
TIFTON GA
31794-1885
US

V. Phone/Fax

Practice location:
  • Phone: 229-382-7898
  • Fax:
Mailing address:
  • Phone: 229-382-7898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberPHOP000045
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberNTP001047
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberNTP001047
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberNTP001047
License Number StateGA

VIII. Authorized Official

Name: JONATHAN PAUL CONNELL
Title or Position: MANAGING MEMBER
Credential:
Phone: 229-382-7898