Healthcare Provider Details

I. General information

NPI: 1841420924
Provider Name (Legal Business Name): ELT INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2009
Last Update Date: 07/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 DAY ST
ROLLING FORK MS
39159-5128
US

IV. Provider business mailing address

PO BOX 490
ROLLING FORK MS
39159-0490
US

V. Phone/Fax

Practice location:
  • Phone: 662-873-6964
  • Fax: 662-873-6020
Mailing address:
  • Phone: 662-873-6964
  • Fax: 662-873-6020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. EMMA LEE TANKSON
Title or Position: PRESIDENT
Credential:
Phone: 662-873-6964