Healthcare Provider Details

I. General information

NPI: 1619310182
Provider Name (Legal Business Name): NORTH DELTA ADULT DAYCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2013
Last Update Date: 04/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 STATELINE RD W
SOUTHAVEN MS
38671-1430
US

IV. Provider business mailing address

1200 STATELINE RD W
SOUTHAVEN MS
38671-1430
US

V. Phone/Fax

Practice location:
  • Phone: 662-393-6128
  • Fax: 662-342-0655
Mailing address:
  • Phone: 662-393-6128
  • Fax: 662-342-0655

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: RAYMOND EARL VALLIER
Title or Position: CEO/ADMINISTRATOR
Credential:
Phone: 662-393-6128