Provider Demographics
NPI:1164222972
Name:SOUTHERN ASSISTED LIVING, LLC
Entity type:Organization
Organization Name:SOUTHERN ASSISTED LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:FC
Authorized Official - Last Name:MUNOZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-918-5443
Mailing Address - Street 1:149 EXECUTIVE CT
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-4159
Mailing Address - Country:US
Mailing Address - Phone:434-799-1930
Mailing Address - Fax:
Practice Address - Street 1:149 EXECUTIVE CT
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-4159
Practice Address - Country:US
Practice Address - Phone:434-799-1930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-19
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility