1235111311 NPI number — BEDFORD CARE CENTER OF PETAL, LLC

Table of content: (NPI 1235111311)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235111311 NPI number — BEDFORD CARE CENTER OF PETAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEDFORD CARE CENTER OF PETAL, 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:
1235111311
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:
908 SOUTH GEORGE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PETAL
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39465-2014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-544-7441
Provider Business Practice Location Address Fax Number:
601-582-3217
Provider Enumeration Date:
11/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WORREL
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
CONTROLLER
Authorized Official Telephone Number:
601-583-3232

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  140 , 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: 00230155 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000080355 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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