MEDICARE: SUGAR GROVE MBH-GA, 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	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1346743481
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUGAR GROVE MBH-GA, LLC

Provider Business Mailing Address
First Line	:	PO BOX 4107
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25364-4107
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	133 HEDRICK DR
Second Line	:
City	:	SUGAR GROVE
State	:	WV
Zip	:	26815-5068
Country	:	US
Telephone Number	:	304-348-1079
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. CYNTHIA PERSILY
Credential	:
Telephone Number	:	304-348-1421

Provider Enumeration Date	:	03/15/2018
Last Update Date	:	03/15/2018

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