Healthcare Provider Details

I. General information

NPI: 1417322587
Provider Name (Legal Business Name): UNITED FAMILY LIFE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2015
Last Update Date: 12/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 S MARTIN LUTHER KING DRIVE
CLEVELAND MS
38732
US

IV. Provider business mailing address

PO BOX 1387
CLEVELAND MS
38732-1387
US

V. Phone/Fax

Practice location:
  • Phone: 662-843-3097
  • Fax:
Mailing address:
  • Phone: 662-843-3097
  • 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: KIMETRIA PARKS
Title or Position: OFFICE MANAGER
Credential:
Phone: 662-843-3097