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General NPI Number Information
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NPI Number | 1558622423
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Entity Type | Organization
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Legal Business Name | NEW DESTINY PERSONAL HOME
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Dates
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Enumeration Date | 06/06/2012
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Last Update Date | 06/06/2012
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Provider Practice Location Address
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Address Line | 308 LONGWOOD DR
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City | STATESBORO
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State | GA
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Zip | 30461-0828
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Country | US
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Telephone | 912-225-6068
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Fax | 912-225-6068
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Provider Business Mailing Address
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Address Line | 308 LONGWOOD DR
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City | STATESBORO
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State | GA
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Zip | 30461-0828
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Country | US
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Telephone | 912-225-6068
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Fax | 912-225-6068
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | EMMETT GEORGE SHERRIFF
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Credential |
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Telephone | 912-225-6068
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 385HR2055X
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Taxonomy Name | Child Mental Illness Respite Care
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License Number | 385HR2055X
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License Number State | GA
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