MEDICARE: HUMANITY UNITED WITH GOD FOR SOCIETY, 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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	060-532-D	GA

General Provider Information

NPI Number	:	1679848295
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HUMANITY UNITED WITH GOD FOR SOCIETY, INC

Provider Business Mailing Address
First Line	:	1203 CLEVELAND AVE
Second Line	:	SUITE 2D
City	:	ATLANTA
State	:	GA
Zip	:	30344-3417
Country	:	US
Telephone Number	:	404-228-2222
Fax Number	:	404-228-2923

Provider Business Practice Location Address
First Line	:	1203 CLEVELAND AVE
Second Line	:	SUITE 2D
City	:	ATLANTA
State	:	GA
Zip	:	30344-3417
Country	:	US
Telephone Number	:	404-228-2222
Fax Number	:	404-228-2923

Authorized Official
Title or Position	:	CEO
Name	:	DERRICK BILLINGSLEA
Credential	:	CCT, CCS
Telephone Number	:	404-228-2222

Provider Enumeration Date	:	03/14/2012
Last Update Date	:	03/14/2012

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