Provider Demographics
NPI:1720260862
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:678-303-2705
Mailing Address - Fax:
Practice Address - Street 1:1283 KENNESTONE CIR
Practice Address - Street 2:SUITE 100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-6029
Practice Address - Country:US
Practice Address - Phone:678-303-2705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health