Provider Demographics
NPI:1831680792
Name:GULF GARDENS RESIDENTIAL AND COMMUNITY LIVING LLC
Entity type:Organization
Organization Name:GULF GARDENS RESIDENTIAL AND COMMUNITY LIVING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF NURSING
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:C
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, FNPC
Authorized Official - Phone:678-237-7183
Mailing Address - Street 1:460 BRIARWOOD DR STE 400
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-3062
Mailing Address - Country:US
Mailing Address - Phone:601-203-1016
Mailing Address - Fax:601-709-4611
Practice Address - Street 1:460 BRIARWOOD DR STE 400
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-3062
Practice Address - Country:US
Practice Address - Phone:601-203-1016
Practice Address - Fax:601-709-4611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-25
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities