Provider Demographics
NPI:1013141357
Name:IDEAL PROVIDER, LLC
Entity Type:Organization
Organization Name:IDEAL PROVIDER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NGOZI
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMUNDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-342-7023
Mailing Address - Street 1:8869 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-1725
Mailing Address - Country:US
Mailing Address - Phone:662-342-7023
Mailing Address - Fax:662-342-7089
Practice Address - Street 1:8869 CENTRE ST # 3
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1725
Practice Address - Country:US
Practice Address - Phone:662-342-7023
Practice Address - Fax:662-342-7089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No282E00000XHospitalsLong Term Care Hospital