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General NPI Number Information
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NPI Number | 1528359189
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Entity Type | Organization
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Legal Business Name | SHANELL'S RESIDENTIAL CARE HOME, INC.
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Dates
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Enumeration Date | 04/29/2011
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Last Update Date | 04/29/2011
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Provider Practice Location Address
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Address Line | 4022 CALIFORNIA AVE
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City | JACKSON
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State | MS
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Zip | 39213-5513
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Country | US
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Telephone | 601-362-4549
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 83040
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City | JACKSON
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State | MS
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Zip | 39283-3040
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Country | US
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Telephone | 601-362-4549
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Fax | 601-713-3513
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. CARNELL KITCHENS
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Credential |
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Telephone | 601-259-4602
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 1035
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License Number State | MS
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