=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215341979
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | METHODIST HOME ROAD ASSISTED LIVING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2014
-----------------------------------------------------
Last Update Date | 06/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4560 METHODIST HOME RD
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39213-4201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 769-257-7232
-----------------------------------------------------
Fax | 769-257-7745
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4560 METHODIST HOME RD
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39213-4201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | KIARA LASHAE JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-918-6415
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------