Provider Demographics
NPI:1407101256
Name:REACH ADULT RECREATION SERVICE, LLC
Entity Type:Organization
Organization Name:REACH ADULT RECREATION SERVICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/LPN
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:SMITH
Authorized Official - Last Name:BOWENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-557-2222
Mailing Address - Street 1:153 E GHOLSON AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38635-3016
Mailing Address - Country:US
Mailing Address - Phone:662-274-3049
Mailing Address - Fax:
Practice Address - Street 1:153 E GHOLSON AVE
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:38635-3016
Practice Address - Country:US
Practice Address - Phone:662-274-3049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-18
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07383030Medicaid