Healthcare Provider Details

I. General information

NPI: 1245415645
Provider Name (Legal Business Name): EMMANUEL RIDGE COMMUNITY SERVICE ORGANIZATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2008
Last Update Date: 01/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2073 HWY 49 SOUTH
FLORENCE MS
39073-1944
US

IV. Provider business mailing address

2073 HIGHWAY 49 S
FLORENCE MS
39073-9422
US

V. Phone/Fax

Practice location:
  • Phone: 601-709-3304
  • Fax: 601-709-3307
Mailing address:
  • Phone: 601-709-3304
  • Fax: 601-709-3307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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