Provider Demographics
NPI:1811232135
Name:FONDREN COVE RELAY, INC.
Entity Type:Organization
Organization Name:FONDREN COVE RELAY, INC.
Other - Org Name:FONDREN COVE ASSITED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CAMMIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:KITCHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-981-3945
Mailing Address - Street 1:PO BOX 55861
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39296-5861
Mailing Address - Country:US
Mailing Address - Phone:601-981-3945
Mailing Address - Fax:
Practice Address - Street 1:4520 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-5307
Practice Address - Country:US
Practice Address - Phone:601-981-3945
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness