=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811596646
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BHG LXVI, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2020
-----------------------------------------------------
Last Update Date | 04/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1021 ALABAMA AVENUE
-----------------------------------------------------
City | BREMEN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-537-7007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5001 SPRING VALLEY ROAD SUITE 600 EAST
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-365-6100
-----------------------------------------------------
Fax | 214-365-6150
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CRED ACCOUNT MANAGER
-----------------------------------------------------
Name | ZACK RAGSDALE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 512-454-5911
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2083A0300X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Preventive Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 2084A0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Psychiatry & Neurology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------