Provider Demographics
NPI:1033516703
Name:SOUTHERN LIVING SERVICES LLC
Entity Type:Organization
Organization Name:SOUTHERN LIVING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:JAYNE
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MEMBER
Authorized Official - Phone:804-550-8674
Mailing Address - Street 1:6688 TATUM RD
Mailing Address - Street 2:
Mailing Address - City:DISPUTANTA
Mailing Address - State:VA
Mailing Address - Zip Code:23842-6902
Mailing Address - Country:US
Mailing Address - Phone:804-550-8674
Mailing Address - Fax:
Practice Address - Street 1:6688 TATUM RD
Practice Address - Street 2:
Practice Address - City:DISPUTANTA
Practice Address - State:VA
Practice Address - Zip Code:23842-6902
Practice Address - Country:US
Practice Address - Phone:804-550-8674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2182171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty