Healthcare Provider Details

I. General information

NPI: 1629310487
Provider Name (Legal Business Name): COMMUNITY ADULT DAY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2013
Last Update Date: 03/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 S EDWARDS AVENUE
MOUND BAYOU MS
38762
US

IV. Provider business mailing address

404 HOLT ST BOX 3
MOUND BAYOU MS
38762-9759
US

V. Phone/Fax

Practice location:
  • Phone: 662-719-2005
  • Fax:
Mailing address:
  • Phone: 662-719-2005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateMS

VIII. Authorized Official

Name: MRS. BEVERLY C JOHNSON
Title or Position: ADMINISTRATOR
Credential: MSW
Phone: 662-719-2005