Organization
MID SOUTH SUPPORTIVE LIVING, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DAVID GAYDEN (EXECUTIVE DIRECTOR)
(901) 458-1181
Entity
Organization
Contact information
Practice address
2600 POPLAR AVE, SUITE 223, MEMPHIS, TN 38112-3851
(901) 458-1181
(901) 324-9669
Mailing address
2600 POPLAR AVE, SUITE 223, MEMPHIS, TN 38112-3851
(901) 458-1181
(901) 324-9669
Taxonomy
Speciality
Code
Description
License number
State
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
Primary
L 3(20)M2-046-6201
TN
Other
Enumeration date
03/07/2007
Last updated
09/03/2009
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