=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952899775
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANIFEST RECOVERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2018
-----------------------------------------------------
Last Update Date | 04/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1215 HIGHTOWER TRL STE 201
-----------------------------------------------------
City | SANDY SPRINGS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30350-6244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-752-5262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1301 SHILOH RD NW STE 1840
-----------------------------------------------------
City | KENNESAW
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30144-7171
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-752-5262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | VICTOR ALFONSO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-212-4659
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------