Healthcare Provider Details

I. General information

NPI: 1306990452
Provider Name (Legal Business Name): HABERSHAM RETREAT, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 11/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

258 PARK AVE
BALDWIN GA
30511-2329
US

IV. Provider business mailing address

258 PARK AVE
BALDWIN GA
30511-2329
US

V. Phone/Fax

Practice location:
  • Phone: 706-778-1749
  • Fax:
Mailing address:
  • Phone: 706-778-1749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRAD L MOORE
Title or Position: C.E.O.
Credential:
Phone: 706-778-1749