Healthcare Provider Details

I. General information

NPI: 1891743274
Provider Name (Legal Business Name): HUMPHREYS COMMUNITY CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 04/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CCC ROAD
BELZONI MS
39038-3806
US

IV. Provider business mailing address

500 CCC ROAD
BELZONI MS
39038-3806
US

V. Phone/Fax

Practice location:
  • Phone: 662-247-1821
  • Fax: 662-247-2078
Mailing address:
  • Phone: 662-247-1821
  • Fax: 662-247-2078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number405
License Number StateMS

VIII. Authorized Official

Name: MRS. RANDY BELTON
Title or Position: AUTHORIZED REPRESENTATIVE
Credential:
Phone: 601-709-1408