Healthcare Provider Details

I. General information

NPI: 1831680792
Provider Name (Legal Business Name): GULF GARDENS RESIDENTIAL AND COMMUNITY LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2018
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 BRIARWOOD DR STE 400
JACKSON MS
39206-3062
US

IV. Provider business mailing address

460 BRIARWOOD DR STE 400
JACKSON MS
39206-3062
US

V. Phone/Fax

Practice location:
  • Phone: 601-203-1016
  • Fax: 601-709-4611
Mailing address:
  • Phone: 601-203-1016
  • Fax: 601-709-4611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE C EDWARDS
Title or Position: DIRECTOR OF NURSING
Credential: MSN, FNPC
Phone: 678-237-7183