=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104456979
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAREFREE LIVING AT HOME LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2020
-----------------------------------------------------
Last Update Date | 01/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 460 BRIARWOOD DR STE 400-1010
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39206-3051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-301-9400
-----------------------------------------------------
Fax | 601-368-8904
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 460 BRIARWOOD DR STE 400-1010
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39206-3051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-618-3099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PATIENT CARE COORDINATOR
-----------------------------------------------------
Name | ANGELA NICHOLE BAILEY
-----------------------------------------------------
Credential | BSN, RN
-----------------------------------------------------
Telephone | 601-618-3099
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------