Provider Demographics
NPI:1790088334
Name:PERSONEL ELDER CARE
Entity Type:Organization
Organization Name:PERSONEL ELDER CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GWEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-334-6335
Mailing Address - Street 1:2353 SOUTH RIDGE CENTER
Mailing Address - Street 2:HWY1 SOUTH
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2353 HIGHWAY 1 S
Practice Address - Street 2:2353 SOUTH RIDGE CENTER
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-8337
Practice Address - Country:US
Practice Address - Phone:662-334-6335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-20
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770570Medicaid