Healthcare Provider Details

I. General information

NPI: 1699930610
Provider Name (Legal Business Name): WARREN-WASHINGTON-ISSAQUENA-SHARKEY-COMMUNITY ACTION AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 MILL RD
GREENVILLE MS
38701-6239
US

IV. Provider business mailing address

1544 OLD LELAND RD
GREENVILLE MS
38701-2656
US

V. Phone/Fax

Practice location:
  • Phone: 662-344-1072
  • Fax:
Mailing address:
  • Phone: 662-378-5857
  • Fax: 662-378-5859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number1021647
License Number StateMS

VIII. Authorized Official

Name: MISS JEAN-MARIE HILL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 662-378-5857