Healthcare Provider Details

I. General information

NPI: 1083171334
Provider Name (Legal Business Name): BEVERLY FORREST-BUTTS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2019
Last Update Date: 02/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 NW DEPOT ST
DURANT MS
39063-3705
US

IV. Provider business mailing address

510 CHURCH ST
WINONA MS
38967-2802
US

V. Phone/Fax

Practice location:
  • Phone: 662-230-0947
  • Fax:
Mailing address:
  • Phone: 662-230-0947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number802066241
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: