MEDICARE: PREVENTIVE CARE HEALTH SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538120258
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREVENTIVE CARE HEALTH SERVICES LLC

Provider Business Mailing Address
First Line	:	PO BOX 458
Second Line	:
City	:	TUNICA
State	:	MS
Zip	:	38676-0458
Country	:	US
Telephone Number	:	662-357-7602
Fax Number	:	662-357-7621

Provider Business Practice Location Address
First Line	:	2073 OLD HIGHWAY 61 N
Second Line	:	STE#2
City	:	TUNICA
State	:	MS
Zip	:	38676
Country	:	US
Telephone Number	:	662-357-7602
Fax Number	:	662-357-7621

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	MS. LYDIA MARIE FRANKLIN
Credential	:	FNP
Telephone Number	:	662-357-7602

Provider Enumeration Date	:	03/31/2006
Last Update Date	:	02/25/2011

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