Healthcare Provider Details

I. General information

NPI: 1720627599
Provider Name (Legal Business Name): AVA SENIORS ACADEMY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2019
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4795 MCWILLIE DR STE 120
JACKSON MS
39206-5628
US

IV. Provider business mailing address

106 LUCKETT ST
GREENWOOD MS
38930-3414
US

V. Phone/Fax

Practice location:
  • Phone: 769-524-4191
  • Fax: 769-524-4208
Mailing address:
  • Phone: 662-299-7236
  • Fax: 662-455-7234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. PEGGY CLAYBORNE
Title or Position: DIRECTOR
Credential:
Phone: 662-299-7236