Provider Demographics
NPI:1033948559
Name:BISON RIDGE RECOVERY LODGE, LLC
Entity type:Organization
Organization Name:BISON RIDGE RECOVERY LODGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-302-3202
Mailing Address - Street 1:4451 ALABAMA HWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-9200
Mailing Address - Country:US
Mailing Address - Phone:770-296-4555
Mailing Address - Fax:706-739-7276
Practice Address - Street 1:224 LAVENDER TRL NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-7896
Practice Address - Country:US
Practice Address - Phone:770-296-4555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder