1447240122 NPI number — CLC OF BOONEVILLE, LLC

Table of content: (NPI 1447240122)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447240122 NPI number — CLC OF BOONEVILLE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLC OF BOONEVILLE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LONGWOOD COMMUNITY LIVING CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447240122
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 LONG ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOONEVILLE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38829-4306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-728-6234
Provider Business Mailing Address Fax Number:
662-728-6944

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 LONG ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOONEVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38829-4306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-728-6234
Provider Business Practice Location Address Fax Number:
662-728-6944
Provider Enumeration Date:
10/25/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WRIGHT
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
662-680-3148

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  155 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0230175 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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