Healthcare Provider Details

I. General information

NPI: 1942664248
Provider Name (Legal Business Name): SACRED TRUST HEALTHCARE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 MAGNOLIA ST
PALATKA FL
32177-8194
US

IV. Provider business mailing address

2424 OXFORD PL
GRETNA LA
70056-3054
US

V. Phone/Fax

Practice location:
  • Phone: 386-916-7582
  • Fax: 504-324-3603
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: MR. COREY THOMAS
Title or Position: ADMINISTRATOR
Credential:
Phone: 386-916-7582