Provider Demographics
NPI:1346319142
Name:DEVEREUX FOUNDATION
Entity Type:Organization
Organization Name:DEVEREUX FOUNDATION
Other - Org Name:DEVEREUX GEORGIA TREATMENT NETWORK
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLIVAR
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:687-303-2669
Mailing Address - Street 1:1283 KENNESTONE CIR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-6029
Mailing Address - Country:US
Mailing Address - Phone:770-427-0147
Mailing Address - Fax:770-423-1502
Practice Address - Street 1:1291 STANLEY RD NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4359
Practice Address - Country:US
Practice Address - Phone:770-427-0147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5910323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA087592297AMedicaid
NC3404521Medicaid
MD700401000Medicaid
WV0002464004Medicaid
NJ8387605Medicare ID - Type UnspecifiedNJ MEDICAID
DC019200400Medicare ID - Type UnspecifiedDC MEDICAID