1578553459 NPI number — VICKSBURG CONVALESCENT, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578553459 NPI number — VICKSBURG CONVALESCENT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VICKSBURG CONVALESCENT, 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:
VICKSBURG CONVALESCENT 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:
1578553459
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9020 OVERLOOK BLVD STE 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-2755
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-250-7100
Provider Business Mailing Address Fax Number:
615-250-7102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1708 CHERRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VICKSBURG
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39180
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-638-3632
Provider Business Practice Location Address Fax Number:
601-638-3998
Provider Enumeration Date:
10/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ORAND
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
615-250-7100

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  176 , 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: 00220334 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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