Healthcare Provider Details

I. General information

NPI: 1497236327
Provider Name (Legal Business Name): PROVIDENCE COMPANION CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2018
Last Update Date: 08/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 HERITAGE DR STE 3B
OXFORD MS
38655
US

IV. Provider business mailing address

PO BOX 2047
CLARKSDALE MS
38614-8047
US

V. Phone/Fax

Practice location:
  • Phone: 662-234-0100
  • Fax: 662-483-1801
Mailing address:
  • Phone: 662-801-2040
  • Fax: 662-483-1801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: CAROLINE FRAZER
Title or Position: PRESIDENT
Credential:
Phone: 662-801-2040