Healthcare Provider Details

I. General information

NPI: 1275456725
Provider Name (Legal Business Name): BLESSED HAVEN INDEPENDENT LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 BEECH ST
MCCOMB MS
39648-5064
US

IV. Provider business mailing address

306 BEECH ST
MCCOMB MS
39648-5064
US

V. Phone/Fax

Practice location:
  • Phone: 769-204-0494
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name: DERRIANA SANTAN LEWIS
Title or Position: OWNER
Credential:
Phone: 769-204-0494