Healthcare Provider Details

I. General information

NPI: 1710382619
Provider Name (Legal Business Name): PATRIOT HOME CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2014
Last Update Date: 01/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 MANGUM AVE
MENDENHALL MS
39114-3015
US

IV. Provider business mailing address

324 MANGUM AVE
MENDENHALL MS
39114-3015
US

V. Phone/Fax

Practice location:
  • Phone: 601-675-7100
  • Fax: 601-675-7007
Mailing address:
  • Phone: 601-675-7100
  • Fax: 601-675-7007

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 Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MS. JAYTORIA MARQUITA-KADESHIA WILKINS
Title or Position: OWNER
Credential:
Phone: 601-896-1644