Healthcare Provider Details

I. General information

NPI: 1164782223
Provider Name (Legal Business Name): SWEET PEA PERSONAL CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9387 BURKHALTER RD
STATESBORO GA
30461-6765
US

IV. Provider business mailing address

PO BOX 983
STATESBORO GA
30459-0983
US

V. Phone/Fax

Practice location:
  • Phone: 954-793-3938
  • Fax:
Mailing address:
  • Phone: 954-793-3938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY YANCEY
Title or Position: CEO
Credential:
Phone: 954-793-3938