Provider Demographics
NPI:1730202219
Name:SRAINTREE VILLAGE
Entity type:Organization
Organization Name:SRAINTREE VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST. ADMIN.
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:229-559-5944
Mailing Address - Street 1:3757 JOHNSTON RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-2105
Mailing Address - Country:US
Mailing Address - Phone:229-559-5944
Mailing Address - Fax:
Practice Address - Street 1:3757 JOHNSTON RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-2105
Practice Address - Country:US
Practice Address - Phone:229-559-5944
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACPA-40075322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children