Healthcare Provider Details

I. General information

NPI: 1912179078
Provider Name (Legal Business Name): TJ3AM3
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 03/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 GREENVIEW DR
VICKSBURG MS
39183-9003
US

IV. Provider business mailing address

104 GREENVIEW DR
VICKSBURG MS
39183-9003
US

V. Phone/Fax

Practice location:
  • Phone: 601-638-6262
  • Fax:
Mailing address:
  • Phone: 601-638-6262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberR870313
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License NumberR870313
License Number StateMS

VIII. Authorized Official

Name: MS. MICHELLE L HAWKINS
Title or Position: R.N. SOLE PROPRIETOR
Credential: RN
Phone: 601-638-6262