=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639757818
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HATTIES SUNFLOWER PLACE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2021
-----------------------------------------------------
Last Update Date | 08/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3925 BETHANIA STATION RD APT 9
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27106-2628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-815-1192
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 756 RONNIE ST
-----------------------------------------------------
City | METTER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30439-3415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ARTANZA SHAW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-726-4605
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------