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General NPI Number Information
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NPI Number | 1346319142
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Entity Type | Organization
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Legal Business Name | DEVEREUX FOUNDATION
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Dates
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Enumeration Date | 11/07/2006
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Last Update Date | 01/16/2009
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Provider Practice Location Address
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Address Line | 1291 STANLEY RD NW
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City | KENNESAW
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State | GA
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Zip | 30152-4359
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Country | US
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Telephone | 770-427-0147
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Fax |
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Provider Business Mailing Address
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Address Line | 1283 KENNESTONE CIR SUITE 100
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City | MARIETTA
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State | GA
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Zip | 30066-6029
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Country | US
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Telephone | 770-427-0147
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Fax | 770-423-1502
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. MARIO BOLIVAR JR.
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Credential |
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Telephone | 687-303-2669
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 323P00000X
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Taxonomy Name | Psychiatric Residential Treatment Facility
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License Number | 5910
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License Number State | GA
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