NPIMap

Organization Active NPI

Devereux Foundation

  • Psychiatric Residential Treatment Facility
  • Kennesaw, GA
National Provider Identifier
1346319142
Registry record updated Jan 16, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatric Residential Treatment FacilityTaxonomy code 323P00000X
License
5910 Issued in GA
Legal business name
DEVEREUX FOUNDATION
Practice address
1291 Stanley Rd NW
Kennesaw, GA 30152-4359
Phone
(770) 427-0147
NPI assigned
Nov 7, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 16, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Mario Bolivar Jr.
Title
Executive Director
Phone
(687) 303-2669

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatric Residential Treatment Facility 323P00000X 5910 GA Primary

Addresses

Primary practice location

1291 Stanley Rd NW
Kennesaw, GA 30152-4359

Mailing address

1283 Kennestone Cir
Suite 100
Marietta, GA 30066-6029
Phone (770) 427-0147

Other identifiers 4

IdentifierTypeStateIssuer
087592297AMedicaidGA
3404521MedicaidNC
700401000MedicaidMD
0002464004MedicaidWV

Other names 1

  • Devereux Georgia Treatment Network Other name

National Provider Directory

National Provider Directory
Tax ID family
Devereux Florida331 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 2

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1162857600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1232064000000",
    "number": "1346319142",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1283 KENNESTONE CIR",
            "address_2": "SUITE 100",
            "city": "MARIETTA",
            "state": "GA",
            "postal_code": "300666029",
            "telephone_number": "770-427-0147",
            "fax_number": "770-423-1502"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1291 STANLEY RD NW",
            "city": "KENNESAW",
            "state": "GA",
            "postal_code": "301524359",
            "telephone_number": "770-427-0147"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEVEREUX FOUNDATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-07",
        "last_updated": "2009-01-16",
        "status": "A",
        "authorized_official_last_name": "BOLIVAR",
        "authorized_official_first_name": "MARIO",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "687-303-2669",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "323P00000X",
            "taxonomy_group": "",
            "desc": "Psychiatric Residential Treatment Facility",
            "state": "GA",
            "license": "5910",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "087592297A",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3404521",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "700401000",
            "state": "MD"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0002464004",
            "state": "WV"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Devereux Georgia Treatment Network",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Kennesaw, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 16, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.