Healthcare Provider Details

I. General information

NPI: 1235651753
Provider Name (Legal Business Name): LE DUJOUR H.E.R.O. VILLAGE OF THE MID-SOUTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2017
Last Update Date: 07/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3750 HACKS CROSS RD STE 102-218
MEMPHIS TN
38125-2367
US

IV. Provider business mailing address

3750 HACKS CROSS RD STE 102-218
MEMPHIS TN
38125-2367
US

V. Phone/Fax

Practice location:
  • Phone: 662-388-0140
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. VACHENZIA MCGRAW-MCKINNEY
Title or Position: CEO
Credential:
Phone: 662-388-0140