Provider Demographics
NPI:1407490816
Name:FULL POTENTIAL ADULT DAYCARE, LLC
Entity Type:Organization
Organization Name:FULL POTENTIAL ADULT DAYCARE, LLC
Other - Org Name:
Other - Org Type:
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:
Authorized Official - Phone:662-563-0690
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:662-563-0690
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:662-563-0690
Practice Address - Fax:662-563-7304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07031582Medicaid