=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144620170
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUFF PLANTATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2014
-----------------------------------------------------
Last Update Date | 04/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 963 BENNOCK MILL RD
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30906-8705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-964-8212
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2300 WINDY RIDGE PKWY SE STE 210
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30339-5665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-691-7855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF RCM
-----------------------------------------------------
Name | TYEAST REYNOLDS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-813-0428
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------