Provider Demographics
NPI:1699242891
Name:SAFE HARBOR CLINIC LLC
Entity type:Organization
Organization Name:SAFE HARBOR CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARMALICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-424-4425
Mailing Address - Street 1:4013 BEATLINE RD STE A
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-4135
Mailing Address - Country:US
Mailing Address - Phone:228-200-0720
Mailing Address - Fax:
Practice Address - Street 1:4013 BEATLINE RD STE A
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560-4135
Practice Address - Country:US
Practice Address - Phone:228-200-0720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-26
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty