Provider Demographics
NPI:1407595028
Name:OPEN WINGS OF OUTREACH CARE
Entity Type:Organization
Organization Name:OPEN WINGS OF OUTREACH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TYETRAUNDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:769-204-9290
Mailing Address - Street 1:219 PARTNERSHIP WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MS
Mailing Address - Zip Code:39429-4505
Mailing Address - Country:US
Mailing Address - Phone:601-633-5177
Mailing Address - Fax:
Practice Address - Street 1:219 PARTNERSHIP WAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429
Practice Address - Country:UM
Practice Address - Phone:601-633-5177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care