Provider Demographics
NPI:1356675433
Name:MALLORY'S HOME FOR THE AGED
Entity Type:Organization
Organization Name:MALLORY'S HOME FOR THE AGED
Other - Org Name:MALLORY'S HOME FOR THE AGED
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LACRECIA
Authorized Official - Middle Name:LASHUN
Authorized Official - Last Name:MCGHEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-503-1505
Mailing Address - Street 1:3123 OVERBROOK DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38128-4637
Mailing Address - Country:US
Mailing Address - Phone:901-503-1505
Mailing Address - Fax:901-937-4887
Practice Address - Street 1:207 WEST PERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-4637
Practice Address - Country:US
Practice Address - Phone:901-503-1505
Practice Address - Fax:901-937-4887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-23
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH445602Medicaid