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General NPI Number Information
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NPI Number | 1598055691
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Entity Type | Organization
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Legal Business Name | SAMO HOLDINGS, INC
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Dates
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Enumeration Date | 04/11/2011
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Last Update Date | 04/11/2011
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Provider Practice Location Address
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Address Line | 5530 SWANSON RD
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City | ELLENWOOD
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State | GA
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Zip | 30294-3857
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Country | US
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Telephone | 404-729-2514
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Fax | 678-264-5461
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Provider Business Mailing Address
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Address Line | 2467 CHAUNCEY LN SW
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City | MARIETTA
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State | GA
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Zip | 30064-4536
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Country | US
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Telephone | 404-729-2514
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Fax | 678-264-5461
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Authorized Official
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Title or Position | CEO
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Name | MOSES DEMBA
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Credential |
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Telephone | 404-729-2514
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | 031013109
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | 031013109
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License Number State | GA
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