Healthcare Provider Details

I. General information

NPI: 1679364079
Provider Name (Legal Business Name): SOUTHERN HOSPITALITY SUPPORT SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2025
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 VALLEY VIEW LN STE 725
IRVING TX
75062-5299
US

IV. Provider business mailing address

212 BURBERRY
GRAND PRAIRIE TX
75052-0033
US

V. Phone/Fax

Practice location:
  • Phone: 214-493-2313
  • Fax:
Mailing address:
  • Phone: 214-493-2313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: SHAMEKA T GRANT
Title or Position: CEO
Credential:
Phone: 214-493-2313