1215170832 NPI number — BEDFORD CARE CENTER OF MARION, LLC

Table of content: (NPI 1215170832)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215170832 NPI number — BEDFORD CARE CENTER OF MARION, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEDFORD CARE CENTER OF MARION, 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:
Provider Other Organization Name Type Code:
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:
1215170832
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 W PINE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HATTIESBURG
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39401-3467
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-583-3232
Provider Business Mailing Address Fax Number:
601-582-7539

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6434A DALE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39342-8704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-294-3515
Provider Business Practice Location Address Fax Number:
601-693-3198
Provider Enumeration Date:
04/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MCELROY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
E
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
601-583-3232

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  524 , 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: 09471018 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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