Provider Demographics
NPI:1174823595
Name:SID'S PLACE INCORPORATED
Entity Type:Organization
Organization Name:SID'S PLACE INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ZANNIE
Authorized Official - Middle Name:DARRELL
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-557-8969
Mailing Address - Street 1:2742 LUKE DR
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-3987
Mailing Address - Country:US
Mailing Address - Phone:678-557-8969
Mailing Address - Fax:404-521-4888
Practice Address - Street 1:2742 LUKE DR
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-3987
Practice Address - Country:US
Practice Address - Phone:678-557-8969
Practice Address - Fax:404-521-4888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031012928310400000X, 320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA992605365AMedicaid