Healthcare Provider Details

I. General information

NPI: 1033508809
Provider Name (Legal Business Name): EMMANUEL RIDGE HOUSING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2015
Last Update Date: 01/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 W MAIN ST
LOUISVILLE MS
39339-2539
US

IV. Provider business mailing address

750 BOLING ST SUITE H
JACKSON MS
39209-2652
US

V. Phone/Fax

Practice location:
  • Phone: 662-705-5031
  • Fax: 662-705-5034
Mailing address:
  • Phone: 769-233-7439
  • Fax: 769-251-0257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateMS

VIII. Authorized Official

Name: MRS. BEATRICE A EZEM
Title or Position: CEO
Credential: RN,CM,CLNC
Phone: 601-927-9839