Healthcare Provider Details

I. General information

NPI: 1063628451
Provider Name (Legal Business Name): COMMUNITY CARE CENTER OF ABERDEEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 04/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 JACKSON ST
ABERDEEN MS
39730-3349
US

IV. Provider business mailing address

505 JACKSON ST
ABERDEEN MS
39730-3349
US

V. Phone/Fax

Practice location:
  • Phone: 662-369-6431
  • Fax: 662-369-6473
Mailing address:
  • Phone: 662-369-6431
  • Fax: 662-369-6473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number561
License Number StateMS

VIII. Authorized Official

Name: MR. DAVID W STALLARD
Title or Position: PROVIDER REPRESENTATIVE
Credential:
Phone: 601-956-8884