Provider Demographics
NPI:1033117304
Name:SATILLA LIFE CARE
Entity Type:Organization
Organization Name:SATILLA LIFE CARE
Other - Org Name:SATILLA HEALTH ENTERPRISES, INC
Other - Org Type:Other Name
Authorized Official - Title/Position:DEPT. HEAD
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:912-287-2506
Mailing Address - Street 1:2007 TEBEAU ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-6358
Mailing Address - Country:US
Mailing Address - Phone:912-285-9153
Mailing Address - Fax:
Practice Address - Street 1:2007 TEBEAU ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-6358
Practice Address - Country:US
Practice Address - Phone:912-285-9153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE00764333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPHRE00764OtherSTATE LICENSE