Provider Demographics
NPI:1427562750
Name:SECOND NATURE BLUE RIDGE, LLC
Entity Type:Organization
Organization Name:SECOND NATURE BLUE RIDGE, LLC
Other - Org Name:DBA BLUE RIDGE THERAPEUTIC WILDERNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-212-2037
Mailing Address - Street 1:PO BOX 809
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:GA
Mailing Address - Zip Code:30525
Mailing Address - Country:US
Mailing Address - Phone:706-212-2037
Mailing Address - Fax:706-212-0354
Practice Address - Street 1:236 FILE ST.
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:GA
Practice Address - Zip Code:30525
Practice Address - Country:US
Practice Address - Phone:706-212-2037
Practice Address - Fax:706-212-0354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-22
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA50017-RCC323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility