Provider Demographics
NPI:1386099679
Name:SB TYBEE LLC
Entity type:Organization
Organization Name:SB TYBEE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:D
Authorized Official - Last Name:FORRISTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-620-7659
Mailing Address - Street 1:26 VAN HORNE AVE
Mailing Address - Street 2:
Mailing Address - City:TYBEE ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31328-9780
Mailing Address - Country:US
Mailing Address - Phone:912-786-4511
Mailing Address - Fax:912-786-7414
Practice Address - Street 1:26 VAN HORNE AVE
Practice Address - Street 2:
Practice Address - City:TYBEE ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31328-9780
Practice Address - Country:US
Practice Address - Phone:912-786-4511
Practice Address - Fax:912-786-7414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
115633Medicare Oscar/Certification