Healthcare Provider Details

I. General information

NPI: 1255694584
Provider Name (Legal Business Name): IN HIS PRESENCE DAYCARE MS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 06/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 BASKET ST
ITTA BENA MS
38941-3206
US

IV. Provider business mailing address

504 BASKET STREET
ITTA BENA MS
38941
US

V. Phone/Fax

Practice location:
  • Phone: 662-931-3646
  • Fax:
Mailing address:
  • Phone: 662-931-3646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number802051112
License Number StateMS

VIII. Authorized Official

Name: MRS. CHANDRA RENA JONES
Title or Position: CEO/OWNER
Credential:
Phone: 663-931-3646