Healthcare Provider Details

I. General information

NPI: 1992191084
Provider Name (Legal Business Name): EMMANUEL RIDGE OF DEKALB INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2015
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14632 HWY 39N/16E
DEKALB MS
39328
US

IV. Provider business mailing address

PO BOX 1522
FLORENCE MS
39073-1522
US

V. Phone/Fax

Practice location:
  • Phone: 601-927-9839
  • Fax:
Mailing address:
  • Phone: 601-927-9839
  • Fax: 769-251-0257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberR815521
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number08752218
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number03630719
License Number StateMS
# 4
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number08752218
License Number StateMS

VIII. Authorized Official

Name: MS. BEATRICE EZEM
Title or Position: CEO
Credential: RN,CM,CLNC
Phone: 601-927-9839