=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497292205
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY FRIEND,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2017
-----------------------------------------------------
Last Update Date | 01/31/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1504 23RD ST N
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39701-2528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-609-4976
-----------------------------------------------------
Fax | 662-223-3061
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1504 23RD ST N
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39701-2528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-609-4976
-----------------------------------------------------
Fax | 662-223-3061
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | TIFFANY RENEE STURDIVANT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 662-609-4976
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 1059530
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number | 1059530
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------