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General NPI Number Information
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NPI Number | 1518440254
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Entity Type | Organization
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Legal Business Name | PRIME HEALTHCARE FOUNDATION - SOUTHERN REGIONAL, LLC
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Dates
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Enumeration Date | 09/10/2018
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Last Update Date | 09/10/2018
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Provider Practice Location Address
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Address Line | 11 UPPER RIVERDALE RD SW
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City | RIVERDALE
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State | GA
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Zip | 30274-2615
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Country | US
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Telephone | 770-991-8160
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Fax | 770-909-2595
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Provider Business Mailing Address
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Address Line | 11 UPPER RIVERDALE RD SW
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City | RIVERDALE
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State | GA
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Zip | 30274-2615
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Country | US
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Telephone | 770-991-8160
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Fax | 770-909-2595
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Authorized Official
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Title or Position | COMPLIANCE OFFICER
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Name | CHRISTOPHER DOAN
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Credential |
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Telephone | 310-259-4706
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 273R00000X
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Taxonomy Name | Psychiatric Hospital Unit
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License Number | 031-710
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License Number State | GA
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