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General NPI Number Information
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NPI Number | 1821393380
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Entity Type | Organization
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Legal Business Name | TIFTON ADDICTION ASSOCIATES, LLC. D/B/A TLC CLINIC
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Dates
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Enumeration Date | 01/14/2011
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Last Update Date | 01/14/2011
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Provider Practice Location Address
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Address Line | 2402 NORTH TIFT AVE SUITE 202
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City | TIFTON
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State | GA
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Zip | 31794
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Country | US
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Telephone | 229-382-7898
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Fax |
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Provider Business Mailing Address
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Address Line | 2402 TIFT AVE N STE 202
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City | TIFTON
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State | GA
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Zip | 31794-1885
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Country | US
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Telephone | 229-382-7898
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | JONATHAN PAUL CONNELL
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Credential |
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Telephone | 229-382-7898
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0802X
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Taxonomy Name | Addiction Psychiatry Physician
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License Number | NTP001047
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 1835P1200X
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Taxonomy Name | Pharmacotherapy Pharmacist
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License Number | PHOP000045
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number | NTP001047
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License Number State | GA
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Taxonomy #4
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Taxonomy Code | 2084A0401X
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Taxonomy Name | Addiction Medicine (Psychiatry & Neurology) Physician
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License Number | NTP001047
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License Number State | GA
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