MEDICARE: SOUTHERN SKY OUTPATIENT DETOX, 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	:	1619740719
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN SKY OUTPATIENT DETOX, LLC

Provider Business Mailing Address
First Line	:	227 SANDY SPRINGS PL # D-298
Second Line	:
City	:	SANDY SPRINGS
State	:	GA
Zip	:	30328-5918
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1810 WATER PL SE STE 180
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30339-2282
Country	:	US
Telephone Number	:	770-659-5944
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	JONATHAN E DENKER III
Credential	:
Telephone Number	:	770-659-5944

Provider Enumeration Date	:	11/01/2023
Last Update Date	:	04/14/2026

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