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General NPI Number Information
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NPI Number | 1205487741
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Entity Type | Organization
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Legal Business Name | COMFORT LIVING PERSONAL CARE
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Dates
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Enumeration Date | 09/26/2019
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Last Update Date | 09/26/2019
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Provider Practice Location Address
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Address Line | 4906 OLD HIGHWAY 11 STE 11
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City | HATTIESBURG
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State | MS
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Zip | 39402-3659
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Country | US
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Telephone | 601-268-0380
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 47
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City | COLUMBIA
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State | MS
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Zip | 39429-0047
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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 | DEMARCUS RIDEOUT
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Credential |
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Telephone | 601-268-0380
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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