Healthcare Provider Details

I. General information

NPI: 1124405840
Provider Name (Legal Business Name): WILLIE MAE CLERK ADULT DAY CARE ,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2015
Last Update Date: 05/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 GAINES HWY
BOYLE MS
38730-9512
US

IV. Provider business mailing address

PO BOX 155
BOYLE MS
38730-0155
US

V. Phone/Fax

Practice location:
  • Phone: 662-846-7732
  • Fax: 662-846-7732
Mailing address:
  • Phone: 662-846-7732
  • Fax: 662-846-7732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number08133227
License Number StateMS

VIII. Authorized Official

Name: MISS JOSEPHINE CLERK
Title or Position: EXECUTIVE DIRECTOR
Credential: RN
Phone: 662-846-7732