MEDICARE: PEACHTREE RECOVERY CENTERS, 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

General Provider Information

NPI Number	:	1528518420
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACHTREE RECOVERY CENTERS, LLC

Provider Business Mailing Address
First Line	:	70 GRUBER LN
Second Line	:	SUITE 107
City	:	ST SIMONS ISLAND
State	:	GA
Zip	:	31522-2881
Country	:	US
Telephone Number	:	404-237-5519
Fax Number	:	404-262-2557

Provider Business Practice Location Address
First Line	:	3975 ROSWELL RD NE
Second Line	:	SUITE 102
City	:	ATLANTA
State	:	GA
Zip	:	30342-4119
Country	:	US
Telephone Number	:	404-237-5519
Fax Number	:	404-262-2557

Authorized Official
Title or Position	:	OWNER
Name	:	BUD HEARN
Credential	:
Telephone Number	:	404-606-0030

Provider Enumeration Date	:	10/04/2016
Last Update Date	:	10/04/2016

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