Healthcare Provider Details

I. General information

NPI: 1497292205
Provider Name (Legal Business Name): FAMILY FRIEND,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2017
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 23RD ST N
COLUMBUS MS
39701-2528
US

IV. Provider business mailing address

1504 23RD ST N
COLUMBUS MS
39701-2528
US

V. Phone/Fax

Practice location:
  • Phone: 662-609-4976
  • Fax: 662-223-3061
Mailing address:
  • Phone: 662-609-4976
  • Fax: 662-223-3061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number1059530
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number1059530
License Number StateMS

VIII. Authorized Official

Name: TIFFANY RENEE STURDIVANT
Title or Position: DIRECTOR
Credential:
Phone: 662-609-4976