Provider Demographics
NPI:1629550363
Name:FONDREN NIGHTINGALES SENIOR DAY RETREAT CO
Entity Type:Organization
Organization Name:FONDREN NIGHTINGALES SENIOR DAY RETREAT CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVY
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:601-398-4485
Mailing Address - Street 1:3321 N WEST ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-3039
Mailing Address - Country:US
Mailing Address - Phone:601-398-4485
Mailing Address - Fax:601-398-1492
Practice Address - Street 1:3321 N WEST ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-3039
Practice Address - Country:US
Practice Address - Phone:601-398-4485
Practice Address - Fax:601-398-1492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-29
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MS261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day CareGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1053622134Medicaid