Provider Demographics
NPI:1053982827
Name:AGAPE RECOVERY HOUSE LLC
Entity type:Organization
Organization Name:AGAPE RECOVERY HOUSE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:BENNETT
Authorized Official - Last Name:BAUCOM
Authorized Official - Suffix:
Authorized Official - Credentials:CACI
Authorized Official - Phone:404-713-4280
Mailing Address - Street 1:2230 TOWNE LAKE PKWY
Mailing Address - Street 2:BLDG 900 STE 200
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-5546
Mailing Address - Country:US
Mailing Address - Phone:404-713-4280
Mailing Address - Fax:
Practice Address - Street 1:2230 TOWNE LAKE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-5540
Practice Address - Country:US
Practice Address - Phone:404-713-4280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-02
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility