Healthcare Provider Details

I. General information

NPI: 1518706399
Provider Name (Legal Business Name): SAMS MEMORIAL COMMUNITY OUTREACH CENTER CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2024
Last Update Date: 05/22/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1072 MORNING GLORY LANE FACILITY
SE DARIEN GA
31305
US

IV. Provider business mailing address

1072 MORNING GLORY LANE FACILITY
SE DARIEN GA
31305
US

V. Phone/Fax

Practice location:
  • Phone: 229-586-1968
  • Fax: 800-997-4617
Mailing address:
  • Phone: 229-586-1968
  • Fax: 800-997-4617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: GLADYS E REED
Title or Position: EXECUTIVE DIRECTOR/CFO
Credential:
Phone: 229-586-1968