Healthcare Provider Details

I. General information

NPI: 1114490323
Provider Name (Legal Business Name): MR. DEVAN LAMONTE STRANGE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2019
Last Update Date: 06/11/2021
Certification Date: 06/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 MIGGINS RD
CANTON MS
39046-9162
US

IV. Provider business mailing address

4780 I 55 N STE 100
JACKSON MS
39211-5583
US

V. Phone/Fax

Practice location:
  • Phone: 601-761-4315
  • Fax:
Mailing address:
  • Phone: 601-761-2025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number801131590
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: