Southern Ave SP LLC

Primary specialty

Assisted Living FacilityTaxonomy code 310400000X

Legal business name

SOUTHERN AVE SP LLC

Practice address

4656 Livingston Rd. SE
Washington DC, DC 20032

Phone

(260) 755-2292

NPI assigned

Dec 21, 2020

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Ryan Person

Title

Director of Business Development

Phone

(260) 413-4159

Specialties & licenses 1

Addresses

Other names 2

• Livingston Place Doing business as
• Livingston Place at Southern Avenue Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1608508800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1611619200000",
    "number": "1306433644",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3630 ILLINOIS RD",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468042062"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4656 LIVINGSTON RD. SE",
            "city": "WASHINGTON DC",
            "state": "DC",
            "postal_code": "20032",
            "telephone_number": "260-755-2292"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN AVE SP LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-12-21",
        "last_updated": "2021-01-26",
        "certification_date": "2021-01-26",
        "status": "A",
        "authorized_official_last_name": "PERSON",
        "authorized_official_first_name": "RYAN",
        "authorized_official_title_or_position": "DIRECTOR OF BUSINESS DEVELOPMENT",
        "authorized_official_telephone_number": "260-413-4159"
    },
    "taxonomies": [
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Livingston Place",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Livingston Place at Southern Avenue",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Tarun Shetty
• Svetlana Sidilkovskaia, DPT
• Carl Siegel, PHD
• Tyrone Sims
• Sirrah Smith Jr.
• Jasmine Stevens
• Christopher Allen Stryker, DDS
• Adeline Takendo I
• Acha Collins Tazoh
• Flavia Tejada Frisancho, M.D

• Assisted Living Facility in Washington DC, DC
• Providers in Washington DC, DC by specialty
• Assisted Living Facility in District of Columbia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 26, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.