Provider Demographics
NPI:1114490323
Name:STRANGE, DEVAN LAMONTE JR
Entity Type:Individual
Prefix:MR
First Name:DEVAN
Middle Name:LAMONTE
Last Name:STRANGE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4780 I 55 N STE 100
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5583
Mailing Address - Country:US
Mailing Address - Phone:601-761-2025
Mailing Address - Fax:
Practice Address - Street 1:177 MIGGINS RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-9162
Practice Address - Country:US
Practice Address - Phone:601-761-4315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-10
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS801131590172A00000X
310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No172A00000XOther Service ProvidersDriver