Healthcare Provider Details

I. General information

NPI: 1134794365
Provider Name (Legal Business Name): ANGEL KEEPER ADULT DAY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2021
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 HIGHWAY 82 E
LELAND MS
38756-9647
US

IV. Provider business mailing address

PO BOX 427
ITTA BENA MS
38941-0427
US

V. Phone/Fax

Practice location:
  • Phone: 662-771-5166
  • Fax: 662-771-5166
Mailing address:
  • Phone: 601-667-7679
  • Fax:

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: DR. VIOLA WILLIAMS MCCASKILL
Title or Position: OWNER
Credential:
Phone: 662-299-5174