1790875730 NPI number — JOYFUL LIVING DDA HOME, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790875730 NPI number — JOYFUL LIVING DDA HOME, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOYFUL LIVING DDA HOME, INC.
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:
6
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:
1790875730
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 13
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELBY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28151-0013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-481-9263
Provider Business Mailing Address Fax Number:
704-481-9263

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 MORTON ST
Provider Second Line Business Practice Location Address:
115 MORTON STREET
Provider Business Practice Location Address City Name:
SHELBY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28152-6621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-481-9263
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRIFFIN
Authorized Official First Name:
JOSEPHINE
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
704-481-9263

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 251S00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 8300515B , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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