1205936002 NPI number — WE CARE COMMUNITY, INC

Table of content: (NPI 1205936002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205936002 NPI number — WE CARE COMMUNITY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WE CARE COMMUNITY, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
JEANS NON MEDICAL CARE RESPITE SERVICES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205936002
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
430 WILLIAMS AVENUE
Provider Second Line Business Mailing Address:
P. O. BOX 72
Provider Business Mailing Address City Name:
SLEDGE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38670
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-382-7754
Provider Business Mailing Address Fax Number:
662-382-7776

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
612 BROAD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRENSHAW
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-382-8883
Provider Business Practice Location Address Fax Number:
662-382-7776
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PHIPPS
Authorized Official First Name:
OZIE
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
662-382-8883

Provider Taxonomy Codes

  • Taxonomy code: 171W00000X , with the licence number:  261QAD600X , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 03138365 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09152532 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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