Provider Demographics
NPI:1124405840
Name:WILLIE MAE CLERK ADULT DAY CARE ,LLC
Entity type:Organization
Organization Name:WILLIE MAE CLERK ADULT DAY CARE ,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:JOSEPHINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLERK
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:662-846-7732
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:BOYLE
Mailing Address - State:MS
Mailing Address - Zip Code:38730-0155
Mailing Address - Country:US
Mailing Address - Phone:662-846-7732
Mailing Address - Fax:662-846-7732
Practice Address - Street 1:151 GAINES HWY
Practice Address - Street 2:
Practice Address - City:BOYLE
Practice Address - State:MS
Practice Address - Zip Code:38730-9512
Practice Address - Country:US
Practice Address - Phone:662-846-7732
Practice Address - Fax:662-846-7732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-01
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08133227261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08133227Medicaid