Healthcare Provider Details

I. General information

NPI: 1780096586
Provider Name (Legal Business Name): REST HAVEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2014
Last Update Date: 05/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

686 COUNTY ROAD 370
ENTERPRISE MS
39330-9727
US

IV. Provider business mailing address

686 COUNTY ROAD 370
ENTERPRISE MS
39330-9727
US

V. Phone/Fax

Practice location:
  • Phone: 601-274-5308
  • Fax:
Mailing address:
  • Phone: 601-274-5308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name: MR. MELVIN LAVERNE MONCRIEF
Title or Position: OWNER/OPERATOR
Credential:
Phone: 601-946-9562