Provider Demographics
NPI:1164782223
Name:SWEET PEA PERSONAL CARE HOME
Entity Type:Organization
Organization Name:SWEET PEA PERSONAL CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:YANCEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-793-3938
Mailing Address - Street 1:PO BOX 983
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-0983
Mailing Address - Country:US
Mailing Address - Phone:954-793-3938
Mailing Address - Fax:
Practice Address - Street 1:9387 BURKHALTER RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30461-6765
Practice Address - Country:US
Practice Address - Phone:954-793-3938
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness