Healthcare Provider Details

I. General information

NPI: 1104177567
Provider Name (Legal Business Name): CARNAGE TENDER LOVING CARE ADC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2012
Last Update Date: 09/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 WHEELER ST
ITTA BENA MS
38941-1919
US

IV. Provider business mailing address

PO BOX 474
ITTA BENA MS
38941-0474
US

V. Phone/Fax

Practice location:
  • Phone: 662-254-0011
  • Fax: 662-254-9511
Mailing address:
  • Phone: 662-254-0011
  • Fax: 662-254-9511

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: MRS. AUGUSTA CARNAGE
Title or Position: OWNER
Credential:
Phone: 662-254-6107