Provider Demographics
NPI:1790835635
Name:GRACE AND MERCY PERSONAL CARE AND RESPITE SERVICE, LLC
Entity Type:Organization
Organization Name:GRACE AND MERCY PERSONAL CARE AND RESPITE SERVICE, LLC
Other - Org Name:GENA'S FOUR SEASONS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SYLVIAETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-488-4027
Mailing Address - Street 1:PO BOX 374
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39060
Mailing Address - Country:US
Mailing Address - Phone:601-488-4027
Mailing Address - Fax:601-488-4128
Practice Address - Street 1:410 MASONIC DRIVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056
Practice Address - Country:US
Practice Address - Phone:601-488-4027
Practice Address - Fax:601-488-4128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08778761Medicaid
MS07680072Medicaid