=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457610453
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY ADVOCATING VOICES OF RESILIENCY TREATMENT CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2012
-----------------------------------------------------
Last Update Date | 05/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 798 RAYS RD SUITE 9496
-----------------------------------------------------
City | STONE MOUNTAIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30083-3144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-499-0078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 798 RAYS RD SUITE 9496
-----------------------------------------------------
City | STONE MOUNTAIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30083-3144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-499-0078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OWNER
-----------------------------------------------------
Name | CARMEN COATES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-587-8286
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------