Provider Demographics
NPI:1538539093
Name:SOUTHERLAND CLARK ENTERPRISES LLC
Entity type:Organization
Organization Name:SOUTHERLAND CLARK ENTERPRISES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLORIOUS
Authorized Official - Middle Name:SHERMAN
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-955-3853
Mailing Address - Street 1:PO BOX 854
Mailing Address - Street 2:
Mailing Address - City:HARLEM
Mailing Address - State:GA
Mailing Address - Zip Code:30814-0854
Mailing Address - Country:US
Mailing Address - Phone:706-955-5558
Mailing Address - Fax:
Practice Address - Street 1:315 N. LOUISVILLE ST.
Practice Address - Street 2:
Practice Address - City:HARLEM
Practice Address - State:GA
Practice Address - Zip Code:30814
Practice Address - Country:US
Practice Address - Phone:706-955-5558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-28
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child