Provider Demographics
NPI:1497551337
Name:KINGSTON WELLNESS RETREAT LLC
Entity type:Organization
Organization Name:KINGSTON WELLNESS RETREAT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP FACILITY OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-797-3264
Mailing Address - Street 1:116 PEACHTREE CT
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-4800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:45 E HOWARD ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:GA
Practice Address - Zip Code:30145-3003
Practice Address - Country:US
Practice Address - Phone:561-797-3264
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility