Provider Demographics
NPI:1538792932
Name:SPRINGWOOD HEALTH & SUPPORTIVE LIVING SERVICES
Entity type:Organization
Organization Name:SPRINGWOOD HEALTH & SUPPORTIVE LIVING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KEANNA
Authorized Official - Middle Name:ANTAJANI
Authorized Official - Last Name:WINTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-404-1908
Mailing Address - Street 1:6447 CHEYENNE DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-5172
Mailing Address - Country:US
Mailing Address - Phone:662-404-1908
Mailing Address - Fax:
Practice Address - Street 1:6447 CHEYENNE DR
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-5172
Practice Address - Country:US
Practice Address - Phone:662-404-1908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1908Medicaid