Provider Demographics
NPI:1679604458
Name:MID SOUTH SUPPORTIVE LIVING, LLC
Entity type:Organization
Organization Name:MID SOUTH SUPPORTIVE LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GAYDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-458-1181
Mailing Address - Street 1:2600 POPLAR AVE
Mailing Address - Street 2:SUITE 223
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38112-3851
Mailing Address - Country:US
Mailing Address - Phone:901-458-1181
Mailing Address - Fax:901-324-9669
Practice Address - Street 1:2600 POPLAR AVE
Practice Address - Street 2:SUITE 223
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38112-3851
Practice Address - Country:US
Practice Address - Phone:901-458-1181
Practice Address - Fax:901-324-9669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL 3(20)M2-046-6201320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities