MEDICARE: ADDICTION HEALING CENTER, LLC

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center		GA

General Provider Information

NPI Number	:	1164772984
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADDICTION HEALING CENTER, LLC

Provider Business Mailing Address
First Line	:	1846 OLD NORCROSS RD
Second Line	:	SUITE 100
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30044-8801
Country	:	US
Telephone Number	:	770-696-9862
Fax Number	:	770-710-0243

Provider Business Practice Location Address
First Line	:	1846 OLD NORCROSS RD
Second Line	:	SUITE 100
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30044-8801
Country	:	US
Telephone Number	:	770-696-9862
Fax Number	:	770-710-0243

Authorized Official
Title or Position	:	CMO
Name	:	DR. SUSAN KAYE BLANK
Credential	:	MD
Telephone Number	:	770-696-9862

Provider Enumeration Date	:	09/19/2012
Last Update Date	:	09/19/2012

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