Healthcare Provider Details

I. General information

NPI: 1730202219
Provider Name (Legal Business Name): SRAINTREE VILLAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3757 JOHNSTON RD
VALDOSTA GA
31601-2105
US

IV. Provider business mailing address

3757 JOHNSTON RD
VALDOSTA GA
31601-2105
US

V. Phone/Fax

Practice location:
  • Phone: 229-559-5944
  • Fax:
Mailing address:
  • Phone: 229-559-5944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberCPA-40075
License Number StateGA

VIII. Authorized Official

Name: MR. EDWARD E SANDERS
Title or Position: ASST. ADMIN.
Credential: LMSW
Phone: 229-559-5944