Provider Demographics
NPI:1023394608
Name:OUR MOMMY'S AND DADDDY'S ADULT DAY CARE CENTER
Entity Type:Organization
Organization Name:OUR MOMMY'S AND DADDDY'S ADULT DAY CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:MAXCINE
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:870-692-5879
Mailing Address - Street 1:1406 E HARDING AVE
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71601-6168
Mailing Address - Country:US
Mailing Address - Phone:870-536-7404
Mailing Address - Fax:
Practice Address - Street 1:1406 E HARDING AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71601-6168
Practice Address - Country:US
Practice Address - Phone:870-536-7404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR146385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR188575755Medicaid