Provider Demographics
NPI:1609131804
Name:BROADMOOR ADULT ENRICHMENT DAYCARE, INC.
Entity Type:Organization
Organization Name:BROADMOOR ADULT ENRICHMENT DAYCARE, INC.
Other - Org Name:NOAH'S ARK DAYCARE CENTER, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:HAYNES
Authorized Official - Last Name:STURGIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-982-8156
Mailing Address - Street 1:5176 KEELE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-4313
Mailing Address - Country:US
Mailing Address - Phone:601-982-8156
Mailing Address - Fax:601-982-8956
Practice Address - Street 1:5176 KEELE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-4313
Practice Address - Country:US
Practice Address - Phone:601-982-8156
Practice Address - Fax:601-982-8956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization