Healthcare Provider Details

I. General information

NPI: 1477975936
Provider Name (Legal Business Name): PRESTIGE SUPERVISED COMMUNITY LIVING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2014
Last Update Date: 01/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 NORTHVIEW DR
MOBILE AL
36618-1801
US

IV. Provider business mailing address

1725 NORTHVIEW DR
MOBILE AL
36618-1801
US

V. Phone/Fax

Practice location:
  • Phone: 251-370-3403
  • Fax: 251-343-9322
Mailing address:
  • Phone: 251-370-3403
  • Fax: 251-343-9322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT BROWN
Title or Position: CEO
Credential:
Phone: 251-370-3403