Provider Demographics
NPI:1710240759
Name:SUPER NATURAL ADULT DAYCARE LLC
Entity Type:Organization
Organization Name:SUPER NATURAL ADULT DAYCARE LLC
Other - Org Name:SUPER NATURAL ADULT DAYCARE LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:GRAYSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-820-0522
Mailing Address - Street 1:1646 DEBRA DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-7817
Mailing Address - Country:US
Mailing Address - Phone:662-820-0522
Mailing Address - Fax:
Practice Address - Street 1:1646 DEBRA DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-7817
Practice Address - Country:US
Practice Address - Phone:662-820-0522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUPER NATURAL ADULT DAYCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA0600X
MS261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care