Healthcare Provider Details

I. General information

NPI: 1508305087
Provider Name (Legal Business Name): WATAUGA RECOVERY CENTER,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

21563 WHYTE HARDEE BLVD
HARDEEVILLE SC
29927
US

IV. Provider business mailing address

3114 BROWNS MILL RD
JOHNSON CITY TN
37604-1417
US

V. Phone/Fax

Practice location:
  • Phone: 843-547-4733
  • Fax: 843-547-4734
Mailing address:
  • Phone: 423-631-0432
  • Fax: 423-631-0284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number40502
License Number StateSC

VIII. Authorized Official

Name: DR. RALPH T REACH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 423-631-0432