Provider Demographics
NPI:1770935611
Name:CRADLE TO THE GRAVE HEALTHCARE LLC
Entity type:Organization
Organization Name:CRADLE TO THE GRAVE HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUTLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-947-1330
Mailing Address - Street 1:PO BOX 1126
Mailing Address - Street 2:
Mailing Address - City:LEAKESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39451-1126
Mailing Address - Country:US
Mailing Address - Phone:601-947-1330
Mailing Address - Fax:601-947-1331
Practice Address - Street 1:413 SAINT FRANCIS ST STE B
Practice Address - Street 2:
Practice Address - City:LEAKESVILLE
Practice Address - State:MS
Practice Address - Zip Code:39451-8909
Practice Address - Country:US
Practice Address - Phone:251-645-4539
Practice Address - Fax:601-947-1331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-03
Last Update Date:2016-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR875627363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty