Healthcare Provider Details

I. General information

NPI: 1366702631
Provider Name (Legal Business Name): NORTH DELTA ADULT DAYCARE OF DREW INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 05/21/2012
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: 877-393-0170
  • Fax: 662-393-0171
Mailing address:
  • Phone: 662-393-0170
  • Fax: 662-393-0171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateMS

VIII. Authorized Official

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