Provider Demographics
NPI:1891449351
Name:STILLWATER SOUTH LLC
Entity Type:Organization
Organization Name:STILLWATER SOUTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-791-3205
Mailing Address - Street 1:4575 WEBB BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4256
Mailing Address - Country:US
Mailing Address - Phone:503-791-3205
Mailing Address - Fax:
Practice Address - Street 1:553 STOVER RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-4508
Practice Address - Country:US
Practice Address - Phone:503-791-3205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility