Provider Demographics
NPI:1073248795
Name:RESTORATION ESSENCE OF A LADY SHELTER, LLC
Entity Type:Organization
Organization Name:RESTORATION ESSENCE OF A LADY SHELTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAKENDRA
Authorized Official - Middle Name:AYANA
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-303-1800
Mailing Address - Street 1:308 CAMELLIA LN
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38751-2604
Mailing Address - Country:US
Mailing Address - Phone:662-303-1800
Mailing Address - Fax:
Practice Address - Street 1:994 BANKHEAD DR
Practice Address - Street 2:
Practice Address - City:BELZONI
Practice Address - State:MS
Practice Address - Zip Code:39038
Practice Address - Country:US
Practice Address - Phone:662-318-5018
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RESTORATION CHILDREN FACILITIES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health