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General NPI Number Information
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NPI Number | 1790536894
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Entity Type | Organization
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Legal Business Name | PEACHTREE DETOX LLC
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Dates
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Enumeration Date | 03/28/2024
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Last Update Date | 11/18/2024
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Provider Practice Location Address
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Address Line | 1008 HIGHWAY 54 W
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-4515
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Country | US
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Telephone | --
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Fax |
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Provider Business Mailing Address
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Address Line | 1008 HIGHWAY 54 W
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-4515
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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 OF 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 | 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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