MEDICARE: SOUTH GEORGIA TREATMENT, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM2800X	Methadone Clinic	NTP-001027	GA

General Provider Information

NPI Number	:	1093963944
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH GEORGIA TREATMENT, INC

Provider Business Mailing Address
First Line	:	794 MCDONOUGH RD
Second Line	:
City	:	JACKSON
State	:	GA
Zip	:	30233-1572
Country	:	US
Telephone Number	:	770-775-9044
Fax Number	:

Provider Business Practice Location Address
First Line	:	794 MCDONOUGH RD
Second Line	:
City	:	JACKSON
State	:	GA
Zip	:	30233-1572
Country	:	US
Telephone Number	:	770-775-9044
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. NICOLE RAE MCCONNELL
Credential	:
Telephone Number	:	770-775-9044

Provider Enumeration Date	:	09/04/2008
Last Update Date	:	09/04/2008

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