Healthcare Provider Details

I. General information

NPI: 1558893958
Provider Name (Legal Business Name): SOUTHERN HOSPITALITY ADULT DAYCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 VANCE RD
GRENADA MS
38901-4830
US

IV. Provider business mailing address

1501 VANCE RD
GRENADA MS
38901-4830
US

V. Phone/Fax

Practice location:
  • Phone: 662-307-2061
  • Fax: 662-307-2316
Mailing address:
  • Phone: 662-307-2061
  • Fax: 662-307-2316

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: CONTRILLA ALEXANDER
Title or Position: OWNER
Credential:
Phone: 662-299-7280