Organization
SID'S PLACE INCORPORATED
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. ZANNIE DARRELL BLACK (OWNER)
(678) 557-8969
Entity
Organization
Contact information
Practice address
2742 LUKE DR, ELLENWOOD, GA 30294-3987
(678) 557-8969
(404) 521-4888
Mailing address
2742 LUKE DR, ELLENWOOD, GA 30294-3987
(678) 557-8969
(404) 521-4888
Taxonomy
Speciality
Code
Description
License number
State
310400000X
Assisted Living Facility
Primary
031012928
GA
320800000X
Mental Illness Community Based Residential Treatment Facility
031012928
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
992605365A
—
GA
Enumeration date
11/01/2010
Last updated
11/01/2010
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