=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134604374
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IRENE'S FAMILY & FRIENDS INDULGENT (IFFI) CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2018
-----------------------------------------------------
Last Update Date | 10/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12502 CRANWOOD LN
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31419-2646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-247-7484
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 LAKEVIEW CT
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31406-6354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-247-7484
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF ADMINISTRATIVE OFFICER (CAO)
-----------------------------------------------------
Name | DR. ALEX KALU
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 912-247-7484
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------