Provider Demographics
NPI:1982952438
Name:SEA BREEZE PERSONAL CARE HOME
Entity Type:Organization
Organization Name:SEA BREEZE PERSONAL CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:THEBAUD
Authorized Official - Suffix:
Authorized Official - Credentials:MS NICOLE THEBAUD
Authorized Official - Phone:678-409-8361
Mailing Address - Street 1:3132 ROBINSON AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTTDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30079-1526
Mailing Address - Country:US
Mailing Address - Phone:678-409-8361
Mailing Address - Fax:
Practice Address - Street 1:3132 ROBINSON AVE
Practice Address - Street 2:
Practice Address - City:SCOTTDALE
Practice Address - State:GA
Practice Address - Zip Code:30079-1526
Practice Address - Country:US
Practice Address - Phone:678-409-8361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities