Healthcare Provider Details

I. General information

NPI: 1720909385
Provider Name (Legal Business Name): FIRST CARE HOME HEATH AGENCY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 HALBERT HEIGHTS RD STE C
BROOKHAVEN MS
39601-3656
US

IV. Provider business mailing address

PO BOX 962
FAYETTE MS
39069-0962
US

V. Phone/Fax

Practice location:
  • Phone: 601-754-5400
  • Fax:
Mailing address:
  • Phone: 601-754-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: KEIQUANAE TATAYANA SMITH
Title or Position: OWNER
Credential:
Phone: 601-754-5400