Provider Demographics
NPI:1033501739
Name:CO-MED ADULT DAY CARE CENTER
Entity Type:Organization
Organization Name:CO-MED ADULT DAY CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TOMEKIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-773-7066
Mailing Address - Street 1:3249 N CHURCH AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339-2072
Mailing Address - Country:US
Mailing Address - Phone:662-773-7066
Mailing Address - Fax:662-773-2677
Practice Address - Street 1:3249 N CHURCH AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39339-2072
Practice Address - Country:US
Practice Address - Phone:662-773-7066
Practice Address - Fax:662-773-2677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05521743251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05521743Medicaid