Provider Demographics
NPI:1871706382
Name:SECOND NATURE BLUE RIDGE
Entity type:Organization
Organization Name:SECOND NATURE BLUE RIDGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-766-6604
Mailing Address - Street 1:236 FILE STREET
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:GA
Mailing Address - Zip Code:30525-3023
Mailing Address - Country:US
Mailing Address - Phone:706-212-2037
Mailing Address - Fax:706-212-0354
Practice Address - Street 1:236 FILE STREET
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:GA
Practice Address - Zip Code:30525-3023
Practice Address - Country:US
Practice Address - Phone:706-212-2037
Practice Address - Fax:706-212-0354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA50017322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50017OtherSTATE LICENSE NUMBER