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General NPI Number Information
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NPI Number | 1457751042
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Entity Type | Organization
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Legal Business Name | SUNNY DALE SERVICE CENTER
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Dates
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Enumeration Date | 09/02/2014
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Last Update Date | 09/02/2014
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Provider Practice Location Address
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Address Line | 611 LAX HWY
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City | OCILLA
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State | GA
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Zip | 31774-2223
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Country | US
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Telephone | 229-468-9494
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Fax | 229-468-7224
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Provider Business Mailing Address
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Address Line | PO BOX 512
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City | OCILLA
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State | GA
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Zip | 31774-0512
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Country | US
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Telephone | 229-468-9494
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Fax | 229-468-7224
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Authorized Official
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Title or Position | DIRECTTOR
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Name | RAYE YOUNG
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Credential |
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Telephone | 229-468-9494
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number | 077R0846
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License Number State | GA
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