Provider Demographics
NPI:1679050454
Name:PHENOMENAL LIVING LLC
Entity Type:Organization
Organization Name:PHENOMENAL LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JERALDINE
Authorized Official - Middle Name:GENEVA
Authorized Official - Last Name:LOVE
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED NURSING AS
Authorized Official - Phone:912-436-5110
Mailing Address - Street 1:2410 BON AIR DR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-2908
Mailing Address - Country:US
Mailing Address - Phone:912-328-7679
Mailing Address - Fax:912-234-0493
Practice Address - Street 1:2410 BON AIR DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-2908
Practice Address - Country:US
Practice Address - Phone:912-328-7679
Practice Address - Fax:912-234-0493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-24
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0012346961163WH0200X
3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty