Provider Demographics
NPI:1457751042
Name:SUNNY DALE SERVICE CENTER
Entity Type:Organization
Organization Name:SUNNY DALE SERVICE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAYE
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-468-9494
Mailing Address - Street 1:PO BOX 512
Mailing Address - Street 2:
Mailing Address - City:OCILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31774-0512
Mailing Address - Country:US
Mailing Address - Phone:229-468-9494
Mailing Address - Fax:229-468-7224
Practice Address - Street 1:611 LAX HWY
Practice Address - Street 2:
Practice Address - City:OCILLA
Practice Address - State:GA
Practice Address - Zip Code:31774-2223
Practice Address - Country:US
Practice Address - Phone:229-468-9494
Practice Address - Fax:229-468-7224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-02
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA077R0846251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services