Healthcare Provider Details

I. General information

NPI: 1891030516
Provider Name (Legal Business Name): MOORHEAD ADULT DAYCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 SMITH ALLEY
SIDON MS
38954-6237
US

IV. Provider business mailing address

119 E PERCY ST
GREENWOOD MS
38930-6237
US

V. Phone/Fax

Practice location:
  • Phone: 662-588-9510
  • Fax:
Mailing address:
  • Phone: 662-588-9510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: LILLIE MAE PRICE
Title or Position: CO-OWNER
Credential:
Phone: 662-588-9510