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General NPI Number Information
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NPI Number | 1275849671
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Entity Type | Organization
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Legal Business Name | PROVIDENCE PCC OF SENATOBIA, LLC
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Dates
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Enumeration Date | 08/23/2010
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Last Update Date | 08/23/2010
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Provider Practice Location Address
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Address Line | 700 MOORES XING
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City | SENATOBIA
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State | MS
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Zip | 38668-8004
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Country | US
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Telephone | 662-562-9229
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Fax | 662-562-9202
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Provider Business Mailing Address
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Address Line | 700 MOORES XING
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City | SENATOBIA
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State | MS
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Zip | 38668-8004
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Country | US
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Telephone | 662-562-9229
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Fax | 662-562-9202
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Authorized Official
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Title or Position | DIRECTOR
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Name | MELANIE ISAACKS
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Credential |
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Telephone | 662-562-9229
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 1032
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License Number State | MS
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