=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396295127
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAINT ANDREWS OUTPATIENT SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2016
-----------------------------------------------------
Last Update Date | 10/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1290 KENNESTONE CIR SUITE102
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30066-6009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-237-5519
-----------------------------------------------------
Fax | 404-262-2557
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 70 GRUBER LN SUITE 107
-----------------------------------------------------
City | ST SIMONS ISLAND
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31522-2881
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-606-0030
-----------------------------------------------------
Fax | 404-262-2557
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BUD HEARN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-606-0030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------