Provider Demographics
NPI:1659556371
Name:THE OLIVER HOUSE ADULT DAYCARE
Entity Type:Organization
Organization Name:THE OLIVER HOUSE ADULT DAYCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERROLYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:601-695-1701
Mailing Address - Street 1:204 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2839
Mailing Address - Country:US
Mailing Address - Phone:601-695-1701
Mailing Address - Fax:601-833-4774
Practice Address - Street 1:2008 HIGHWAY 51
Practice Address - Street 2:
Practice Address - City:WESSON
Practice Address - State:MS
Practice Address - Zip Code:39191-9502
Practice Address - Country:US
Practice Address - Phone:601-643-1533
Practice Address - Fax:601-643-1534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS172A00000X311ZA0620X
MS251QA0600X311ZA0620X
MS376J00000X311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04387341Medicaid
MS01330234Medicaid
MS03037821Medicaid