=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558613505
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DODDSVILLE ADULT DAY CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2012
-----------------------------------------------------
Last Update Date | 10/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 133 MILLER
-----------------------------------------------------
City | DODDSVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38736-8736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-588-2000
-----------------------------------------------------
Fax | 662-756-0141
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 698
-----------------------------------------------------
City | RULEVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38771-0698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-588-2000
-----------------------------------------------------
Fax | 662-745-0141
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. DOROTHY BURTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 662-588-2000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number | NONE REQUIRED
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------