# MID SOUTH SUPPORTIVE LIVING, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1679604458
- **Authorized official:** MR. DAVID GAYDEN (EXECUTIVE DIRECTOR)
- **Authorized official phone:** (901) 458-1181

## Contact information

- **Practice address:** 2600 POPLAR AVE, SUITE 223, MEMPHIS, TN 38112-3851
- **Practice address phone:** (901) 458-1181
- **Practice address fax:** (901) 324-9669
- **Mailing address:** 2600 POPLAR AVE, SUITE 223, MEMPHIS, TN 38112-3851
- **Mailing address phone:** (901) 458-1181
- **Mailing address fax:** (901) 324-9669

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 320600000X | Intellectual and/or Developmental Disabilities Residential Treatment Facility | L 3(20)M2-046-6201 | TN | Yes |

## Other

- **Enumeration date:** 03/07/2007
- **Last updated:** 09/03/2009