NPIMap

Organization Active NPI

Safe Harbor Clinic LLC

  • Psychiatry Physician
  • Long Beach, MS
National Provider Identifier
1699242891
Registry record updated Oct 26, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
Legal business name
SAFE HARBOR CLINIC LLC
Doing business as
Safe Harbor Clinic LLC
Practice address
4013 Beatline Rd Ste a
Long Beach, MS 39560-4135
Phone
(228) 200-0720
NPI assigned
Oct 26, 2018
Last updated
Oct 26, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 26, 2018

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

Authorized official

Name
Dr. Dustin Marmalich, MDNPI 1093135154
Title
Owner
Phone
(228) 424-4425

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health Counselor 101YM0800X NU
Psychiatry Physician 2084P0800X NU Primary
Multi-Specialty Clinic/Center 261QM1300X NU

Addresses

Primary practice location

4013 Beatline Rd Ste a
Long Beach, MS 39560-4135

Mailing address

4013 Beatline Rd Ste a
Long Beach, MS 39560-4135
Phone (228) 200-0720

Other names 1

  • Safe Harbor Clinic LLC Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190626001020 MS Part B Supplier - Clinic/Group Practice 1759615693 Receives reassigned benefits from 12 practitioners
Practice locations: Long Beach, MS; Gulfport, MS

National Provider Directory

National Provider Directory

Locations

15255 Community Rd
Gulfport, MS 39503
Phone (228) 832-0790

4011 Beatline Rd
Ste 7
Long Beach, MS 39560
Phone (228) 200-0720

Practitioners & affiliated clinicians

Practitioners 13

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 13

NPI Registry JSON

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

{
    "created_epoch": "1540512000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1540512000000",
    "number": "1699242891",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4013 BEATLINE RD STE A",
            "city": "LONG BEACH",
            "state": "MS",
            "postal_code": "395604135",
            "telephone_number": "228-200-0720"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4013 BEATLINE RD STE A",
            "city": "LONG BEACH",
            "state": "MS",
            "postal_code": "395604135",
            "telephone_number": "228-200-0720"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SAFE HARBOR CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-10-26",
        "last_updated": "2018-10-26",
        "status": "A",
        "authorized_official_last_name": "MARMALICH",
        "authorized_official_first_name": "DUSTIN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "228-424-4425",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Safe Harbor Clinic LLC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Long Beach, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 26, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.