Healthcare Provider Details

I. General information

NPI: 1851125504
Provider Name (Legal Business Name): ONE HEART, MANY SMILES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2024
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

437 JORDON RIDGE PL
MADISON MS
39110-8340
US

IV. Provider business mailing address

437 JORDON RIDGE PL
MADISON MS
39110-8340
US

V. Phone/Fax

Practice location:
  • Phone: 601-291-8098
  • Fax:
Mailing address:
  • Phone: 601-291-8098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code385HR2065X
TaxonomyChild Physical Disabilities Respite Care
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: AIYSHA JOHNSON-BURKS
Title or Position: OWNER
Credential:
Phone: 601-291-8098