Provider Demographics
NPI:1932643939
Name:RELIANCE TREATMENT CENTER OF STATESBORO
Entity Type:Organization
Organization Name:RELIANCE TREATMENT CENTER OF STATESBORO
Other - Org Name:RELIANCE TREATMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORAINE
Authorized Official - Middle Name:E
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-489-7827
Mailing Address - Street 1:201 DONEHOO ST
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-5120
Mailing Address - Country:US
Mailing Address - Phone:912-489-7827
Mailing Address - Fax:912-225-3791
Practice Address - Street 1:201 DONEHOO ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5120
Practice Address - Country:US
Practice Address - Phone:912-489-7827
Practice Address - Fax:912-225-3791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-09
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANTP001063251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GANTP001063OtherNTC LICENSE NUMBER