Provider Demographics
NPI:1194901397
Name:PRIVATE HOME AND PERSONAL CARE SERVICE
Entity type:Organization
Organization Name:PRIVATE HOME AND PERSONAL CARE SERVICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FORTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-328-9862
Mailing Address - Street 1:53 FULGHAM DR
Mailing Address - Street 2:P.O. BOX 8553
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2829
Mailing Address - Country:US
Mailing Address - Phone:662-904-1066
Mailing Address - Fax:662-328-9862
Practice Address - Street 1:53 FULGHAM DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2829
Practice Address - Country:US
Practice Address - Phone:662-904-1066
Practice Address - Fax:662-328-9862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00374024Medicaid
MS03875729Medicaid