Provider Demographics
NPI:1629310487
Name:COMMUNITY ADULT DAY CARE
Entity Type:Organization
Organization Name:COMMUNITY ADULT DAY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:662-719-2005
Mailing Address - Street 1:404 HOLT ST
Mailing Address - Street 2:BOX 3
Mailing Address - City:MOUND BAYOU
Mailing Address - State:MS
Mailing Address - Zip Code:38762-9759
Mailing Address - Country:US
Mailing Address - Phone:662-719-2005
Mailing Address - Fax:
Practice Address - Street 1:114 S EDWARDS AVENUE
Practice Address - Street 2:
Practice Address - City:MOUND BAYOU
Practice Address - State:MS
Practice Address - Zip Code:38762
Practice Address - Country:US
Practice Address - Phone:662-719-2005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care