Provider Demographics
NPI:1841650538
Name:PERSONAL RECOVERY NETWORK LLC
Entity type:Organization
Organization Name:PERSONAL RECOVERY NETWORK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAGTACHIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-548-2589
Mailing Address - Street 1:250 CORPORATE CENTER CT
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6388
Mailing Address - Country:US
Mailing Address - Phone:770-389-8100
Mailing Address - Fax:
Practice Address - Street 1:4015 S COBB DR SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6303
Practice Address - Country:US
Practice Address - Phone:770-431-2354
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PERSONAL RECOVERY NETWORK LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-02-24
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty