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General NPI Number Information
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NPI Number | 1386916864
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Entity Type | Organization
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Legal Business Name | SAVIOR OF LIFE THERAPEUTIC RESIDENTIAL GROUP HOME
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Dates
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Enumeration Date | 01/31/2012
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Last Update Date | 01/31/2012
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Provider Practice Location Address
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Address Line | 411 NAPLES RD
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City | JACKSON
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State | MS
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Zip | 39206-5918
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Country | US
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Telephone | 601-398-2974
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Fax | 601-487-6227
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Provider Business Mailing Address
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Address Line | 411 NAPLES RD
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City | JACKSON
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State | MS
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Zip | 39206-5918
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Country | US
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Telephone | 601-398-2974
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Fax | 601-487-6227
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Authorized Official
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Title or Position | SOCIAL WORKER/FOUNDER
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Name | MRS. ANGELA LAMBERT WRIGHT
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Credential | BSW
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Telephone | 601-454-6419
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | CYS-SOL-TGH-02
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License Number State | MS
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