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General NPI Number Information
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NPI Number | 1679604458
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Entity Type | Organization
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Legal Business Name | MID SOUTH SUPPORTIVE LIVING, LLC
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Dates
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Enumeration Date | 03/07/2007
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Last Update Date | 09/03/2009
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Provider Practice Location Address
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Address Line | 2600 POPLAR AVE SUITE 223
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City | MEMPHIS
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State | TN
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Zip | 38112-3851
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Country | US
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Telephone | 901-458-1181
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Fax | 901-324-9669
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Provider Business Mailing Address
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Address Line | 2600 POPLAR AVE SUITE 223
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City | MEMPHIS
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State | TN
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Zip | 38112-3851
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Country | US
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Telephone | 901-458-1181
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Fax | 901-324-9669
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. DAVID GAYDEN
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Credential |
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Telephone | 901-458-1181
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | L 3(20)M2-046-6201
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License Number State | TN
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