1548927296 NPI number — PHARAOH'S REST HAVEN, L.L.C

Table of content: (NPI 1548927296)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548927296 NPI number — PHARAOH'S REST HAVEN, L.L.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHARAOH'S REST HAVEN, L.L.C
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:
1548927296
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1044 S MARTIN LUTHER KING JR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49203-3273
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-879-7434
Provider Business Mailing Address Fax Number:
517-539-5943

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1044 S MARTIN LUTHER KING JR DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49203-3273
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-879-7434
Provider Business Practice Location Address Fax Number:
517-539-5943
Provider Enumeration Date:
11/17/2021

Additional Information

Authorized Official

Authorized Official Last Name:
GIBSON
Authorized Official First Name:
JZSA-JAZA
Authorized Official Middle Name:
ANDRE
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
517-879-7434

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1922548114 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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