Provider Demographics
NPI:1780293787
Name:STARKVILLE PEDIATRIC EXTENDED CARE LLC
Entity type:Organization
Organization Name:STARKVILLE PEDIATRIC EXTENDED CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-232-1518
Mailing Address - Street 1:8178 SOLDIER CT
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-6135
Mailing Address - Country:US
Mailing Address - Phone:251-232-1518
Mailing Address - Fax:
Practice Address - Street 1:9771 MS HIGHWAY 25
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-4944
Practice Address - Country:US
Practice Address - Phone:251-232-1518
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-26
Last Update Date:2020-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care