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General NPI Number Information
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NPI Number | 1679134183
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Entity Type | Organization
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Legal Business Name | SUNSET RESIDENTIAL CENTER LLC
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Dates
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Enumeration Date | 06/25/2019
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Last Update Date | 06/25/2019
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Provider Practice Location Address
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Address Line | 20114B HIGHWAY 18
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City | HERMANVILLE
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State | MS
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Zip | 39086-9747
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Country | US
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Telephone | 601-535-2059
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Fax | 601-535-2059
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Provider Business Mailing Address
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Address Line | 20114B HIGHWAY 18
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City | HERMANVILLE
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State | MS
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Zip | 39086-9747
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Country | US
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Telephone | 601-535-2059
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Fax | 601-535-2059
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Authorized Official
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Title or Position | OWNER
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Name | MRS. GLORIA JEAN SHOULDERS
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Credential | PRESIDENT
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Telephone | 601-831-2371
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number |
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License Number State |
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