Healthcare Provider Details

I. General information

NPI: 1861210130
Provider Name (Legal Business Name): THE VILLAGE OF SACRED MELANIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2024
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 HARMON AVE
FORT STEWART GA
31314-5641
US

IV. Provider business mailing address

946 ELMA G MILES PKWY STE 1011006
HINESVILLE GA
31313-8076
US

V. Phone/Fax

Practice location:
  • Phone: 912-435-6633
  • Fax:
Mailing address:
  • Phone: 352-362-8175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name: SATIN GORDON
Title or Position: DOULA
Credential: CLD
Phone: 352-362-8175