Provider Demographics
NPI:1679155337
Name:ATLANTA DETOX CENTER, LLC
Entity type:Organization
Organization Name:ATLANTA DETOX CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSING AND CREDENTIALING SPECIAL
Authorized Official - Prefix:
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-807-8471
Mailing Address - Street 1:277 MEDICAL WAY
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2522
Mailing Address - Country:US
Mailing Address - Phone:470-298-7236
Mailing Address - Fax:470-300-8480
Practice Address - Street 1:277 MEDICAL WAY
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2522
Practice Address - Country:US
Practice Address - Phone:470-298-7236
Practice Address - Fax:470-300-8480
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATLANTA DETOX CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)