1174823595 NPI number — SID'S PLACE INCORPORATED

Table of content: (NPI 1174823595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174823595 NPI number — SID'S PLACE INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SID'S PLACE INCORPORATED
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174823595
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2742 LUKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLENWOOD
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30294-3987
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-557-8969
Provider Business Mailing Address Fax Number:
404-521-4888

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2742 LUKE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLENWOOD
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30294-3987
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-557-8969
Provider Business Practice Location Address Fax Number:
404-521-4888
Provider Enumeration Date:
11/01/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BLACK
Authorized Official First Name:
ZANNIE
Authorized Official Middle Name:
DARRELL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
678-557-8969

Provider Taxonomy Codes

  • Taxonomy code: 320800000X , with the licence number:  031012928 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 310400000X , with the licence number: 031012928 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 992605365A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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