Provider Demographics
NPI:1740524099
Name:SOUTH WEST ADULT DAY CARE
Entity type:Organization
Organization Name:SOUTH WEST ADULT DAY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-919-6131
Mailing Address - Street 1:5210 BROOKLEIGH DR
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-6009
Mailing Address - Country:US
Mailing Address - Phone:601-919-6131
Mailing Address - Fax:
Practice Address - Street 1:5638 TERRY RD
Practice Address - Street 2:
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272-9200
Practice Address - Country:US
Practice Address - Phone:601-919-6131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSNO LIC FOR MS252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1215284278OtherMEDICARE CERTIFICATION IS PENDING