Provider Demographics
NPI:1013484161
Name:SUPPORTIVE LIVING LLC
Entity Type:Organization
Organization Name:SUPPORTIVE LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAKENDRIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-400-1553
Mailing Address - Street 1:117 OAK TERRACE LN
Mailing Address - Street 2:
Mailing Address - City:HARVEST
Mailing Address - State:AL
Mailing Address - Zip Code:35749-1202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 OAK TERRACE LN
Practice Address - Street 2:
Practice Address - City:HARVEST
Practice Address - State:AL
Practice Address - Zip Code:35749-1202
Practice Address - Country:US
Practice Address - Phone:256-400-1553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-26
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No385H00000XRespite Care FacilityRespite Care