Provider Demographics
NPI:1538120258
Name:PREVENTIVE CARE HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:PREVENTIVE CARE HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FRANKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:662-357-7602
Mailing Address - Street 1:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:TUNICA
Mailing Address - State:MS
Mailing Address - Zip Code:38676-0458
Mailing Address - Country:US
Mailing Address - Phone:662-357-7602
Mailing Address - Fax:662-357-7621
Practice Address - Street 1:2073 OLD HIGHWAY 61 N
Practice Address - Street 2:STE#2
Practice Address - City:TUNICA
Practice Address - State:MS
Practice Address - Zip Code:38676
Practice Address - Country:US
Practice Address - Phone:662-357-7602
Practice Address - Fax:662-357-7621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015951Medicaid
MS258958Medicare ID - Type Unspecified