1386916864 NPI number — SAVIOR OF LIFE THERAPEUTIC RESIDENTIAL GROUP HOME

Table of content: (NPI 1386916864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386916864 NPI number — SAVIOR OF LIFE THERAPEUTIC RESIDENTIAL GROUP HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAVIOR OF LIFE THERAPEUTIC RESIDENTIAL GROUP HOME
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386916864
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
411 NAPLES RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39206-5918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-398-2974
Provider Business Mailing Address Fax Number:
601-487-6227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
411 NAPLES RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39206-5918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-398-2974
Provider Business Practice Location Address Fax Number:
601-487-6227
Provider Enumeration Date:
01/31/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WRIGHT
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
LAMBERT
Authorized Official Title or Position:
SOCIAL WORKER/FOUNDER
Authorized Official Telephone Number:
601-454-6419

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X , with the licence number:  CYS-SOL-TGH-02 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)