=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659731826
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHRINK SAVANNAH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2016
-----------------------------------------------------
Last Update Date | 07/30/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 ABERCORN ST
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31401-7521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-712-2550
-----------------------------------------------------
Fax | 912-480-0518
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1601 ABERCORN ST
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31401-7521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-712-2550
-----------------------------------------------------
Fax | 912-480-0518
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CHAD BROCK
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 912-712-2550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------