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General NPI Number Information
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NPI Number | 1053811257
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Entity Type | Organization
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Legal Business Name | CUSTOM CARE CONSULTANTS, LLC
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Dates
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Enumeration Date | 02/15/2018
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Last Update Date | 02/15/2018
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Provider Practice Location Address
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Address Line | 1403 VAN BUREN AVE
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City | OXFORD
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State | MS
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Zip | 38655-4091
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Country | US
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Telephone | 601-813-9535
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Fax |
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Provider Business Mailing Address
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Address Line | 1403 VAN BUREN AVE
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City | OXFORD
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State | MS
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Zip | 38655-4091
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | ELLIS WINTON MCINNIS IV
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Credential |
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Telephone | 601-813-9535
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number | 1066035
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License Number State | MS
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