MEDICARE: BEDFORD CARE CENTER OF PETAL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	140	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000080355	OTHER	MS	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1235111311
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEDFORD CARE CENTER OF PETAL, LLC

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

Provider Business Practice Location Address
First Line	:	908 SOUTH GEORGE STREET
Second Line	:
City	:	PETAL
State	:	MS
Zip	:	39465-2014
Country	:	US
Telephone Number	:	601-544-7441
Fax Number	:	601-582-3217

Authorized Official
Title or Position	:	CONTROLLER
Name	:	MR. STEPHEN A. WORREL
Credential	:
Telephone Number	:	601-583-3232

Provider Enumeration Date	:	11/15/2005
Last Update Date	:	01/15/2010

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