1013488923 NPI number — COVENANT ADULT DAY CARE OF TUNICA

Table of content: (NPI 1013488923)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013488923 NPI number — COVENANT ADULT DAY CARE OF TUNICA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COVENANT ADULT DAY CARE OF TUNICA
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:
Provider Other Organization Name Type Code:
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:
1013488923
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1004
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUNICA
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38676-1004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-392-1064
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1041 HIGHWAY 61 S STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUNICA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38676-9130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-392-1064
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/17/2018

Additional Information

Authorized Official

Authorized Official Last Name:
STEWART
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
662-392-1064

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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