Provider Demographics
NPI:1992191084
Name:EMMANUEL RIDGE OF DEKALB INC
Entity Type:Organization
Organization Name:EMMANUEL RIDGE OF DEKALB INC
Other - Org Name:ADULT DAYCARE HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:BEATRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:EZEM
Authorized Official - Suffix:
Authorized Official - Credentials:RN,CM,CLNC
Authorized Official - Phone:601-927-9839
Mailing Address - Street 1:PO BOX 1522
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MS
Mailing Address - Zip Code:39073-1522
Mailing Address - Country:US
Mailing Address - Phone:601-927-9839
Mailing Address - Fax:769-251-0257
Practice Address - Street 1:14632 HWY 39N/16E
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:MS
Practice Address - Zip Code:39328
Practice Address - Country:US
Practice Address - Phone:601-927-9839
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-15
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR815521163WA2000X
MS08752218251T00000X, 261QA0600X
MS03630719253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No163WA2000XNursing Service ProvidersRegistered NurseAdministratorGroup - Multi-Specialty
No251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08752218Medicaid