Healthcare Provider Details

I. General information

NPI: 1609352384
Provider Name (Legal Business Name): SAFE HARBOR CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2018
Last Update Date: 08/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4013 BEATLINE RD STE A
LONG BEACH MS
39560
US

IV. Provider business mailing address

4013 BEATLINE RD STE A
LONG BEACH MS
39560-4135
US

V. Phone/Fax

Practice location:
  • Phone: 228-200-0720
  • Fax: 228-200-0383
Mailing address:
  • Phone: 228-200-0720
  • Fax: 228-200-0383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC9311
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25543
License Number StateMS

VIII. Authorized Official

Name: DUSTIN MARMALICH
Title or Position: OWNER
Credential: MD
Phone: 228-200-0720