Healthcare Provider Details

I. General information

NPI: 1760737621
Provider Name (Legal Business Name): FOOTPRINTS ADULT DAY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2012
Last Update Date: 07/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 NORTHSIDE DR
NEWTON MS
39345-2384
US

IV. Provider business mailing address

701 NORTHSIDE DR
NEWTON MS
39345-2361
US

V. Phone/Fax

Practice location:
  • Phone: 601-683-4200
  • Fax:
Mailing address:
  • Phone: 601-683-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberCMRC-BCS-ALZD-01
License Number StateMS

VIII. Authorized Official

Name: MS. DEBBIE J. FERGUSON
Title or Position: DIRECTOR
Credential:
Phone: 601-683-4201