Provider Demographics
NPI:1619740719
Name:SOUTHERN SKY OUTPATIENT DETOX, LLC
Entity Type:Organization
Organization Name:SOUTHERN SKY OUTPATIENT DETOX, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:DENKER
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:770-659-5944
Mailing Address - Street 1:227 SANDY SPRINGS PL # D-298
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5918
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 WATER PL SE STE 180
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-2061
Practice Address - Country:US
Practice Address - Phone:770-659-5944
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder