Healthcare Provider Details

I. General information

NPI: 1578081410
Provider Name (Legal Business Name): WOODLAND ADULT CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MARKET ST
WOODLAND MS
39776-9105
US

IV. Provider business mailing address

PO BOX 186
WOODLAND MS
39776-0186
US

V. Phone/Fax

Practice location:
  • Phone: 662-456-0111
  • Fax: 662-456-0111
Mailing address:
  • Phone: 662-456-0133
  • Fax: 662-456-7335

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: MS. JERRY SULLIVAN
Title or Position: OWNER
Credential:
Phone: 662-456-0133