Provider Demographics
NPI:1083157804
Name:FULL POTENTIAL SENIOR SOLUTIONS
Entity Type:Organization
Organization Name:FULL POTENTIAL SENIOR SOLUTIONS
Other - Org Name:FULL POTENTIAL MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TAMEKIA
Authorized Official - Middle Name:RENIX
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:662-563-0670
Mailing Address - Street 1:405 HIGHWAY 51 S
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38606-2549
Mailing Address - Country:US
Mailing Address - Phone:662-563-0670
Mailing Address - Fax:662-563-7304
Practice Address - Street 1:405 HIGHWAY 51 S
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:MS
Practice Address - Zip Code:38606-2549
Practice Address - Country:US
Practice Address - Phone:662-563-0670
Practice Address - Fax:662-563-7304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15048/11.1332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies