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General NPI Number Information
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NPI Number | 1497551337
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Entity Type | Organization
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Legal Business Name | KINGSTON WELLNESS RETREAT LLC
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Dates
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Enumeration Date | 02/21/2025
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Last Update Date | 11/26/2025
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Provider Practice Location Address
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Address Line | 45 E HOWARD ST
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City | KINGSTON
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State | GA
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Zip | 30145-3003
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Country | US
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Telephone | 561-797-3264
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Fax |
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Provider Business Mailing Address
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Address Line | 100 GOVERNORS TRCE STE 101
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City | PEACHTREE CITY
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State | GA
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Zip | 30269-4853
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | VP FACILITY OPERATIONS
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Name | DANIELLE CRAIG
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Credential |
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Telephone | 561-797-3264
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 323P00000X
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Taxonomy Name | Psychiatric Residential Treatment Facility
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License Number |
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License Number State |
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