Provider Demographics
NPI:1871879213
Name:MARTHA'S CARE PCA AGENCY
Entity type:Organization
Organization Name:MARTHA'S CARE PCA AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:6015-439-4882
Mailing Address - Street 1:791 GOODHOPE ROAD
Mailing Address - Street 2:
Mailing Address - City:BASSFIELD
Mailing Address - State:MS
Mailing Address - Zip Code:39421
Mailing Address - Country:US
Mailing Address - Phone:601-543-9482
Mailing Address - Fax:
Practice Address - Street 1:791 GOODHOPE ROAD
Practice Address - Street 2:
Practice Address - City:BASSFIELD
Practice Address - State:MS
Practice Address - Zip Code:39421
Practice Address - Country:US
Practice Address - Phone:601-543-9482
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS253Z00000X253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care