Provider Demographics
NPI:1417353103
Name:MID SOUTH SENIOR CARE, LLC
Entity Type:Organization
Organization Name:MID SOUTH SENIOR CARE, LLC
Other - Org Name:MID-SOUTH SENIOR CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:CHAD
Authorized Official - Last Name:GILLILAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-766-7660
Mailing Address - Street 1:5050 POPLAR AVE
Mailing Address - Street 2:SUITE 2400
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38157-0101
Mailing Address - Country:US
Mailing Address - Phone:901-766-7660
Mailing Address - Fax:901-328-1353
Practice Address - Street 1:5050 POPLAR AVE
Practice Address - Street 2:SUITE 2400
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38157-0101
Practice Address - Country:US
Practice Address - Phone:901-766-7660
Practice Address - Fax:901-328-1353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-07
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL000000013736253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH445514Medicaid