Provider Demographics
NPI:1386950145
Name:PERSONAL CARE HOME OF WIGGINS
Entity type:Organization
Organization Name:PERSONAL CARE HOME OF WIGGINS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:C
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-325-4577
Mailing Address - Street 1:918 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:WIGGINS
Mailing Address - State:MS
Mailing Address - Zip Code:39577-8750
Mailing Address - Country:US
Mailing Address - Phone:601-928-4663
Mailing Address - Fax:601-928-4668
Practice Address - Street 1:918 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-8750
Practice Address - Country:US
Practice Address - Phone:601-928-4663
Practice Address - Fax:601-928-4668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-30
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1038310400000X, 3104A0625X, 3104A0630X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances