Provider Demographics
NPI:1700214574
Name:SUMTER YOUTH DEVELPMENT CAMPUS
Entity Type:Organization
Organization Name:SUMTER YOUTH DEVELPMENT CAMPUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR HEALTH SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:STAPLES HORNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-508-6681
Mailing Address - Street 1:300 MCMATH MILL ROAD
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31714-8669
Mailing Address - Country:US
Mailing Address - Phone:229-931-5800
Mailing Address - Fax:
Practice Address - Street 1:300 MCMATH MILL RD
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31719-8669
Practice Address - Country:US
Practice Address - Phone:229-931-5800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA DEPARTMENT OF JUVENILE JUSTICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-14
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN125194322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children