Provider Demographics
NPI:1417508110
Name:HARRIS, MAXINE DELORES
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:DELORES
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 383
Mailing Address - Street 2:
Mailing Address - City:ARCOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38722-0383
Mailing Address - Country:US
Mailing Address - Phone:662-378-7962
Mailing Address - Fax:662-827-7347
Practice Address - Street 1:104 MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:ARCOLA
Practice Address - State:MS
Practice Address - Zip Code:38722
Practice Address - Country:US
Practice Address - Phone:662-827-7500
Practice Address - Fax:662-827-7347
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1043310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility