Provider Demographics
NPI:1750766697
Name:ST. JOHN'S PERSONAL CARE SERVICES, LLC
Entity type:Organization
Organization Name:ST. JOHN'S PERSONAL CARE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADFORD, JR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-647-1766
Mailing Address - Street 1:PO BOX 3
Mailing Address - Street 2:409 STATE STREET
Mailing Address - City:INDIANOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38751-0000
Mailing Address - Country:US
Mailing Address - Phone:662-647-1766
Mailing Address - Fax:
Practice Address - Street 1:517 E BAKER ST
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:MS
Practice Address - Zip Code:38751-2503
Practice Address - Country:US
Practice Address - Phone:166-264-7766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-21
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care