Sid'S Place Incorporated

Primary specialty

Assisted Living FacilityTaxonomy code 310400000X

License

031012928 Issued in GA

Legal business name

SID'S PLACE INCORPORATED

Practice address

2742 Luke Dr
Ellenwood, GA 30294-3987

Phone

(678) 557-8969

Fax

(404) 521-4888

NPI assigned

Nov 1, 2010

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Zannie Darrell Black

Title

Owner

Phone

(678) 557-8969

Specialties & licenses 2

Addresses

Other identifiers 1

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1288569600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1288569600000",
    "number": "1174823595",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2742 LUKE DR",
            "city": "ELLENWOOD",
            "state": "GA",
            "postal_code": "302943987",
            "telephone_number": "678-557-8969",
            "fax_number": "404-521-4888"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2742 LUKE DR",
            "city": "ELLENWOOD",
            "state": "GA",
            "postal_code": "302943987",
            "telephone_number": "678-557-8969",
            "fax_number": "404-521-4888"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SID'S PLACE INCORPORATED",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-11-01",
        "last_updated": "2010-11-01",
        "status": "A",
        "authorized_official_last_name": "BLACK",
        "authorized_official_first_name": "ZANNIE",
        "authorized_official_middle_name": "DARRELL",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "678-557-8969",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": "GA",
            "license": "031012928",
            "primary": true
        },
        {
            "code": "320800000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Mental Illness",
            "state": "GA",
            "license": "031012928",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "992605365A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Assisted Living Facility in Ellenwood, GA
• Providers in Ellenwood, GA by specialty
• Assisted Living Facility in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 1, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.