Provider Demographics
NPI:1164772984
Name:ADDICTION HEALING CENTER, LLC
Entity Type:Organization
Organization Name:ADDICTION HEALING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:KAYE
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-696-9862
Mailing Address - Street 1:1846 OLD NORCROSS RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-8801
Mailing Address - Country:US
Mailing Address - Phone:770-696-9862
Mailing Address - Fax:770-710-0243
Practice Address - Street 1:1846 OLD NORCROSS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-8801
Practice Address - Country:US
Practice Address - Phone:770-696-9862
Practice Address - Fax:770-710-0243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder