Provider Demographics
NPI:1013283688
Name:PORT CITY ADULT DAYCARE
Entity Type:Organization
Organization Name:PORT CITY ADULT DAYCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETTIE
Authorized Official - Middle Name:JO
Authorized Official - Last Name:PRUITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-701-5856
Mailing Address - Street 1:PO BOX 5453
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38704-5453
Mailing Address - Country:US
Mailing Address - Phone:662-701-5856
Mailing Address - Fax:662-796-0611
Practice Address - Street 1:1255 S RACEWAY RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-8208
Practice Address - Country:US
Practice Address - Phone:662-701-5856
Practice Address - Fax:662-796-0611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care