MEDICARE: CHRISTOPHER'S PERSONAL CARE HOME, LLC

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	871	MS

General Provider Information

NPI Number	:	1598020703
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHRISTOPHER'S PERSONAL CARE HOME, LLC

Provider Business Mailing Address
First Line	:	885 HIGHWAY 178 E
Second Line	:
City	:	HOLLY SPRINGS
State	:	MS
Zip	:	38635-2641
Country	:	US
Telephone Number	:	662-551-1122
Fax Number	:	662-551-1635

Provider Business Practice Location Address
First Line	:	885 HIGHWAY 178 E
Second Line	:
City	:	HOLLY SPRINGS
State	:	MS
Zip	:	38635-2641
Country	:	US
Telephone Number	:	662-551-1122
Fax Number	:	662-551-1635

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	MS. GAIL M HOUCK
Credential	:	RN
Telephone Number	:	662-551-1122

Provider Enumeration Date	:	07/13/2012
Last Update Date	:	07/13/2012

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