=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356675433
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MALLORY'S HOME FOR THE AGED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2009
-----------------------------------------------------
Last Update Date | 09/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 207 WEST PERSON AVE
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38128-4637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-503-1505
-----------------------------------------------------
Fax | 901-937-4887
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3123 OVERBROOK DR
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38128-4637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-503-1505
-----------------------------------------------------
Fax | 901-937-4887
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. LACRECIA LASHUN MCGHEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 901-503-1505
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------