Healthcare Provider Details

I. General information

NPI: 1710823547
Provider Name (Legal Business Name): IBN ABDULLAH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2026
Last Update Date: 04/24/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 FAIRMONT DR
SAVANNAH GA
31406
US

IV. Provider business mailing address

60 CALICO CT
MIDWAY GA
31320-4480
US

V. Phone/Fax

Practice location:
  • Phone: 912-221-5250
  • Fax:
Mailing address:
  • Phone: 904-304-8948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-525985
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: