Provider Demographics
NPI:1104177567
Name:CARNAGE TENDER LOVING CARE ADC
Entity type:Organization
Organization Name:CARNAGE TENDER LOVING CARE ADC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AUGUSTA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARNAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-254-6107
Mailing Address - Street 1:PO BOX 474
Mailing Address - Street 2:
Mailing Address - City:ITTA BENA
Mailing Address - State:MS
Mailing Address - Zip Code:38941-0474
Mailing Address - Country:US
Mailing Address - Phone:662-254-0011
Mailing Address - Fax:662-254-9511
Practice Address - Street 1:102 WHEELER ST
Practice Address - Street 2:
Practice Address - City:ITTA BENA
Practice Address - State:MS
Practice Address - Zip Code:38941-1919
Practice Address - Country:US
Practice Address - Phone:662-254-0011
Practice Address - Fax:662-254-9511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care