=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356780829
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PICKENS ADULT DAYCARE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2013
-----------------------------------------------------
Last Update Date | 06/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 345 HWY 51 N
-----------------------------------------------------
City | PICKENS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-278-6739
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1032 PEYTON AVE
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39209-7013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-278-6739
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. MARIE D. PICKENS
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 601-278-6739
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 347E00000X
-----------------------------------------------------
Taxonomy Name | Transportation Broker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------