MEDICARE: MAXINE DELORES HARRIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	1043	MS

General Provider Information

NPI Number	:	1417508110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAXINE DELORES HARRIS

Provider Business Mailing Address
First Line	:	PO BOX 383
Second Line	:
City	:	ARCOLA
State	:	MS
Zip	:	38722-0383
Country	:	US
Telephone Number	:	662-378-7962
Fax Number	:	662-827-7347

Provider Business Practice Location Address
First Line	:	104 MARTIN LUTHER KING BLVD
Second Line	:
City	:	ARCOLA
State	:	MS
Zip	:	38722
Country	:	US
Telephone Number	:	662-827-7500
Fax Number	:	662-827-7347

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/24/2019
Last Update Date	:	09/24/2019

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Directions to “ MAXINE DELORES HARRIS ” Practice Location

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