Provider Demographics
NPI:1093120354
Name:SENIOR LIVING AGENCY
Entity Type:Organization
Organization Name:SENIOR LIVING AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNA
Authorized Official - Middle Name:LATOYA
Authorized Official - Last Name:SENIOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-515-6113
Mailing Address - Street 1:414 N WEST ST
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39817-3678
Mailing Address - Country:US
Mailing Address - Phone:229-515-6113
Mailing Address - Fax:229-299-8689
Practice Address - Street 1:414 N WEST ST
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39817-3678
Practice Address - Country:US
Practice Address - Phone:229-515-6113
Practice Address - Fax:229-299-8689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-25
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health