Healthcare Provider Details

I. General information

NPI: 1821171505
Provider Name (Legal Business Name): SEA PALM CIRCLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 SEA PALM CIR
SAVANNAH GA
31410-2658
US

IV. Provider business mailing address

5 SEA PALM CIR
SAVANNAH GA
31410-2658
US

V. Phone/Fax

Practice location:
  • Phone: 912-898-3278
  • Fax: 912-898-3279
Mailing address:
  • Phone: 912-898-3278
  • Fax: 912-898-3279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateGA

VIII. Authorized Official

Name: CHARLES LI
Title or Position: RHA
Credential:
Phone: 912-356-2011