Provider Demographics
NPI:1386035335
Name:SHANE'S CRIB
Entity Type:Organization
Organization Name:SHANE'S CRIB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:E
Authorized Official - Last Name:MAINOR
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:912-385-2583
Mailing Address - Street 1:1303 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31545-7757
Mailing Address - Country:US
Mailing Address - Phone:912-385-2583
Mailing Address - Fax:912-385-2583
Practice Address - Street 1:1303 SOUTH 1ST STREET
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545
Practice Address - Country:US
Practice Address - Phone:912-385-2583
Practice Address - Fax:912-385-2583
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MASA TAKE BY FORCE MINISTRIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW003662324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility