=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376059766
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A HOME AWAY FROM HOME ADULT DAY CARE SERVICES, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2017
-----------------------------------------------------
Last Update Date | 12/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 155 CARRIAGE HOUSE DR STE A
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38305-3975
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-736-4044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 155 CARRIAGE HOUSE DR STE A
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38305-3975
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-736-4044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SARAH A MCCURRY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 731-747-5112
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number | 1X117099T
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------