=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962044131
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STILL WATERS ADULT DAY FACILITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2019
-----------------------------------------------------
Last Update Date | 10/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 BRANTLEY ST
-----------------------------------------------------
City | OPP
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36467-1720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-400-2932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 BRANTLEY ST
-----------------------------------------------------
City | OPP
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36467-1720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-400-2932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JEANETTE M WATERS
-----------------------------------------------------
Credential | PRESIDENT,LPN
-----------------------------------------------------
Telephone | 334-400-2932
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------