Provider Demographics
NPI:1497007207
Name:TUNICA ADULT DAY CARE
Entity Type:Organization
Organization Name:TUNICA ADULT DAY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BILLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-363-2001
Mailing Address - Street 1:PO BOX 2774
Mailing Address - Street 2:
Mailing Address - City:TUNICA
Mailing Address - State:MS
Mailing Address - Zip Code:38676-2774
Mailing Address - Country:US
Mailing Address - Phone:662-363-2001
Mailing Address - Fax:
Practice Address - Street 1:1530 EDWARDS AVE
Practice Address - Street 2:
Practice Address - City:TUNICA
Practice Address - State:MS
Practice Address - Zip Code:38676-9372
Practice Address - Country:US
Practice Address - Phone:662-363-2001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-04
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSNONE REQUIRED302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization