Healthcare Provider Details

I. General information

NPI: 1023145380
Provider Name (Legal Business Name): SCG CORAL LANDING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 OLD MOULTRIE RD
ST AUGUSTINE FL
32086-5454
US

IV. Provider business mailing address

16 NORCROSS ST SUITE 100
ROSWELL GA
33075-3864
US

V. Phone/Fax

Practice location:
  • Phone: 904-794-2273
  • Fax: 904-794-2267
Mailing address:
  • Phone: 770-255-1810
  • Fax: 770-255-0059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT DANIEL VAUGHAN
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 770-255-1810