Healthcare Provider Details

I. General information

NPI: 1093651374
Provider Name (Legal Business Name): SHALOM RESIDENTIAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 BARRINGTON CV
MEMPHIS TN
38125-3701
US

IV. Provider business mailing address

4940 BARRINGTON CV
MEMPHIS TN
38125-3701
US

V. Phone/Fax

Practice location:
  • Phone: 901-279-3020
  • Fax:
Mailing address:
  • Phone: 901-279-3020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: THIERRY MUKAMA
Title or Position: OWNER
Credential:
Phone: 901-279-3020