Healthcare Provider Details

I. General information

NPI: 1598055691
Provider Name (Legal Business Name): SAMO HOLDINGS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2011
Last Update Date: 04/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5530 SWANSON RD
ELLENWOOD GA
30294-3857
US

IV. Provider business mailing address

2467 CHAUNCEY LN SW
MARIETTA GA
30064-4536
US

V. Phone/Fax

Practice location:
  • Phone: 404-729-2514
  • Fax: 678-264-5461
Mailing address:
  • Phone: 404-729-2514
  • Fax: 678-264-5461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number031013109
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number031013109
License Number StateGA

VIII. Authorized Official

Name: MOSES DEMBA
Title or Position: CEO
Credential:
Phone: 404-729-2514