Provider Demographics
NPI:1700205705
Name:EXCLUSIVE RESIDENTIAL SERVICE LLC
Entity Type:Organization
Organization Name:EXCLUSIVE RESIDENTIAL SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCMILLION-JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-423-8197
Mailing Address - Street 1:2117 LUCKNER CT
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36618-2618
Mailing Address - Country:US
Mailing Address - Phone:251-341-1764
Mailing Address - Fax:
Practice Address - Street 1:2117 LUCKNER CT
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36618-2618
Practice Address - Country:US
Practice Address - Phone:251-341-1764
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-08
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities