1790835635 NPI number — GRACE AND MERCY PERSONAL CARE AND RESPITE SERVICE, LLC

Table of content: PATRICK J. LYTLE DO (NPI 1811996580)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790835635 NPI number — GRACE AND MERCY PERSONAL CARE AND RESPITE SERVICE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRACE AND MERCY PERSONAL CARE AND RESPITE SERVICE, LLC
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:
6
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:
1790835635
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 374
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-488-4027
Provider Business Mailing Address Fax Number:
601-488-4128

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 MASONIC DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLINTON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-488-4027
Provider Business Practice Location Address Fax Number:
601-488-4128
Provider Enumeration Date:
01/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
SYLVIAETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
601-488-4027

Provider Taxonomy Codes

  • Taxonomy code: 376J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 08778761 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 07680072 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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