Healthcare Provider Details

I. General information

NPI: 1093120602
Provider Name (Legal Business Name): FIDELTYHEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2014
Last Update Date: 06/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 GARETT DRIVE
TERRY MS
39170
US

IV. Provider business mailing address

127 GARETT DRIVE
TERRY MS
39170
US

V. Phone/Fax

Practice location:
  • Phone: 601-397-2953
  • Fax:
Mailing address:
  • Phone: 601-397-2953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: SHAVONDA FIELDS
Title or Position: OWNER
Credential:
Phone: 601-397-2953