=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821524075
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HIS HOUSE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2017
-----------------------------------------------------
Last Update Date | 05/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5010 MOUNT ZION RD
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37172-7130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-881-6417
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5010 MT ZION RD
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-881-6417
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | CONNIE MITCHELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 931-881-6417
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | TNPL536621
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------