Provider Demographics
NPI:1477869881
Name:PROVIDENCE PCC OF GRENADA, LLC
Entity Type:Organization
Organization Name:PROVIDENCE PCC OF GRENADA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:P
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-226-8556
Mailing Address - Street 1:1855 HILL DR
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-5003
Mailing Address - Country:US
Mailing Address - Phone:662-226-8556
Mailing Address - Fax:662-229-0556
Practice Address - Street 1:1855 HILL DR
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5003
Practice Address - Country:US
Practice Address - Phone:662-226-8556
Practice Address - Fax:662-229-0556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-23
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS777310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility