1346559226 NPI number — SOVEREIGN HOUSE OF RESPITE, LLC

Table of content: (NPI 1346559226)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346559226 NPI number — SOVEREIGN HOUSE OF RESPITE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOVEREIGN HOUSE OF RESPITE, LLC
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:
SOVEREIGN HOUSE AGENCY, LLC
Provider Other Organization Name Type Code:
3
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:
1346559226
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5977 WHITESVILLE RD
Provider Second Line Business Mailing Address:
UNIT 14
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31904-3660
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-221-6281
Provider Business Mailing Address Fax Number:
706-221-6289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5977 WHITESVILLE RD
Provider Second Line Business Practice Location Address:
UNIT 14
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31904-3660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-221-6281
Provider Business Practice Location Address Fax Number:
706-221-6289
Provider Enumeration Date:
09/27/2010

Additional Information

Authorized Official

Authorized Official Last Name:
JOLLY / LEWIS
Authorized Official First Name:
VICKY / GLORIA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNERS/ADMINISTRATORS
Authorized Official Telephone Number:
706-304-4325

Provider Taxonomy Codes

  • Taxonomy code: 385H00000X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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