Healthcare Provider Details

I. General information

NPI: 1154611085
Provider Name (Legal Business Name): ELITE ADULT DAYCARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2011
Last Update Date: 04/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BIZZELL STREET
PACE MS
38764-0162
US

IV. Provider business mailing address

P.O. BOX 162 101 BIZZELL STREET
PACE MS
38764-0162
US

V. Phone/Fax

Practice location:
  • Phone: 662-723-0034
  • Fax: 662-723-0034
Mailing address:
  • Phone: 662-723-0034
  • Fax: 662-723-0034

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: MS. BRENDA JEAN BRYANT
Title or Position: OWNER
Credential:
Phone: 662-723-0034