Healthcare Provider Details

I. General information

NPI: 1346743481
Provider Name (Legal Business Name): SUGAR GROVE MBH-GA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2018
Last Update Date: 03/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 HEDRICK DR
SUGAR GROVE WV
26815-5068
US

IV. Provider business mailing address

PO BOX 4107
CHARLESTON WV
25364-4107
US

V. Phone/Fax

Practice location:
  • Phone: 304-348-1079
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: DR. CYNTHIA PERSILY
Title or Position: CEO
Credential:
Phone: 304-348-1421