Provider Demographics
NPI:1639495682
Name:BOBBY BENNETT HOST HOME
Entity Type:Organization
Organization Name:BOBBY BENNETT HOST HOME
Other - Org Name:SATILLA COMMUNITY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GLYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:912-449-7103
Mailing Address - Street 1:4156 WHITE TAIL WAY
Mailing Address - Street 2:
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516-5204
Mailing Address - Country:US
Mailing Address - Phone:912-449-8601
Mailing Address - Fax:
Practice Address - Street 1:1007 MARY ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31503-3823
Practice Address - Country:US
Practice Address - Phone:912-449-7111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SATILLA COMMUNITY SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities