Provider Demographics
NPI:1245735950
Name:SOUTHERN BREEZE PCH
Entity Type:Organization
Organization Name:SOUTHERN BREEZE PCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-799-0308
Mailing Address - Street 1:127 S BELAIR RD
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-9111
Mailing Address - Country:US
Mailing Address - Phone:706-799-0308
Mailing Address - Fax:706-504-4162
Practice Address - Street 1:127 S BELAIR RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-9111
Practice Address - Country:US
Practice Address - Phone:706-799-0308
Practice Address - Fax:706-504-4162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003143758AMedicaid