Provider Demographics
NPI:1033440805
Name:TOXICOLOGY ASSOCIATES OF NORTH GEORGIA GWINNETT, INC.
Entity Type:Organization
Organization Name:TOXICOLOGY ASSOCIATES OF NORTH GEORGIA GWINNETT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM SPONSOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:KEELAGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:770-248-1616
Mailing Address - Street 1:2221 PEACHTREE RD NE
Mailing Address - Street 2:#D-291
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1148
Mailing Address - Country:US
Mailing Address - Phone:770-248-1616
Mailing Address - Fax:770-248-1618
Practice Address - Street 1:1895 BEAVER RIDGE CIR
Practice Address - Street 2:SUITE N
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-3840
Practice Address - Country:US
Practice Address - Phone:770-248-1616
Practice Address - Fax:770-248-1618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANTO001031261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone