Healthcare Provider Details

I. General information

NPI: 1740724046
Provider Name (Legal Business Name): NORTH STREET ADULT DAYCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2016
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 NORTH ST
CLEVELAND MS
38732-2746
US

IV. Provider business mailing address

222 NORTH ST
CLEVELAND MS
38732-2746
US

V. Phone/Fax

Practice location:
  • Phone: 662-843-5758
  • Fax: 662-843-5311
Mailing address:
  • Phone: 662-843-5758
  • Fax: 662-843-5311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER GROSSLEY
Title or Position: OWNER
Credential:
Phone: 662-843-5758