Provider Demographics
NPI:1528359189
Name:SHANELL'S RESIDENTIAL CARE HOME, INC.
Entity Type:Organization
Organization Name:SHANELL'S RESIDENTIAL CARE HOME, INC.
Other - Org Name:SHANELL'S RESIDENTIAL CARE HOME, INC. (ASSISTANT LIVING)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CARNELL
Authorized Official - Middle Name:
Authorized Official - Last Name:KITCHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-259-4602
Mailing Address - Street 1:PO BOX 83040
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39283-3040
Mailing Address - Country:US
Mailing Address - Phone:601-362-4549
Mailing Address - Fax:601-713-3513
Practice Address - Street 1:4022 CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-5513
Practice Address - Country:US
Practice Address - Phone:601-362-4549
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-29
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1035310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility