=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083171334
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BEVERLY FORREST-BUTTS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2019
-----------------------------------------------------
Last Update Date | 02/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 407 NW DEPOT ST
-----------------------------------------------------
City | DURANT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39063-3705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-230-0947
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 510 CHURCH ST
-----------------------------------------------------
City | WINONA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38967-2802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-230-0947
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number | 802066241
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------