=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356899579
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PILGRIM REST PERSONAL CARE & RESPITE SERVICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2016
-----------------------------------------------------
Last Update Date | 11/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 MCWILLIAMS STREET
-----------------------------------------------------
City | WINSTONVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38781-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-741-2020
-----------------------------------------------------
Fax | 662-741-2831
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P O BOX 125
-----------------------------------------------------
City | WINSTONVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38781-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-741-2020
-----------------------------------------------------
Fax | 662-741-2831
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | GLORIA JEFFERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 662-719-3672
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 385H00000X
-----------------------------------------------------
Taxonomy Name | Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------