Healthcare Provider Details

I. General information

NPI: 1619484482
Provider Name (Legal Business Name): SILVER LIGHT ADULT DAYCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2018
Last Update Date: 01/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 CALLAWAY CIR
BYRAM MS
39272-4499
US

IV. Provider business mailing address

142 CALLAWAY CIR
BYRAM MS
39272-4499
US

V. Phone/Fax

Practice location:
  • Phone: 769-218-7005
  • Fax: 601-665-4430
Mailing address:
  • Phone: 769-218-7005
  • Fax: 601-665-4430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. JOHNNY EARL WILSON JR.
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 769-218-7005