Healthcare Provider Details

I. General information

NPI: 1881931368
Provider Name (Legal Business Name): MATURE CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2013
Last Update Date: 10/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1967 HOSPITAL DR
CLARKSDALE MS
38614-7203
US

IV. Provider business mailing address

1967 HOSPITAL DR
CLARKSDALE MS
38614-7203
US

V. Phone/Fax

Practice location:
  • Phone: 662-627-1500
  • Fax:
Mailing address:
  • Phone: 662-627-1500
  • Fax:

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: BOULDIN A MARLEY
Title or Position: PRESIDENT
Credential: MD
Phone: 662-902-4135