Healthcare Provider Details

I. General information

NPI: 1457678625
Provider Name (Legal Business Name): GRENADA NORTH DELTA HOSPICE & PALLIATIVE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 12/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 N MAIN ST
DREW MS
38737-3406
US

IV. Provider business mailing address

123 STATELINE RD E
SOUTHAVEN MS
38671-1710
US

V. Phone/Fax

Practice location:
  • Phone: 662-745-0587
  • Fax: 662-745-0589
Mailing address:
  • Phone: 662-393-0170
  • Fax: 662-393-0171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number137
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number132
License Number StateMS

VIII. Authorized Official

Name: MR. RAYMOND E VALLIER
Title or Position: ADMINISTRATOR
Credential:
Phone: 662-393-0170