=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972936821
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGAPE HOSPICE CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2013
-----------------------------------------------------
Last Update Date | 10/17/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1774 MAIN ST
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38671-1215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-253-8605
-----------------------------------------------------
Fax | 662-253-8814
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1774 MAIN ST
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38671-1215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-253-8605
-----------------------------------------------------
Fax | 662-253-8814
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. JACKY LEE MATTHEWS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 662-253-8605
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251G00000X
-----------------------------------------------------
Taxonomy Name | Community Based Hospice Care Agency
-----------------------------------------------------
License Number | 222
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------