=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700205705
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXCLUSIVE RESIDENTIAL SERVICE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2014
-----------------------------------------------------
Last Update Date | 05/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2117 LUCKNER CT
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36618-2618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-341-1764
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2117 LUCKNER CT
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36618-2618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-341-1764
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SHIRLEY A. MCMILLION-JACKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 251-423-8197
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------