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General NPI Number Information
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NPI Number | 1871706382
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Entity Type | Organization
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Legal Business Name | SECOND NATURE BLUE RIDGE
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Dates
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Enumeration Date | 05/08/2007
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Last Update Date | 05/29/2012
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Provider Practice Location Address
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Address Line | 236 FILE STREET
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City | CLAYTON
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State | GA
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Zip | 30525-3023
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Country | US
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Telephone | 706-212-2037
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Fax | 706-212-0354
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Provider Business Mailing Address
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Address Line | 236 FILE STREET
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City | CLAYTON
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State | GA
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Zip | 30525-3023
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Country | US
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Telephone | 706-212-2037
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Fax | 706-212-0354
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Authorized Official
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Title or Position | BUSINESS OFFICE
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Name | ANGIE EVANS
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Credential |
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Telephone | 801-766-6604
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | 50017
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License Number State | GA
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