Healthcare Provider Details

I. General information

NPI: 1528249570
Provider Name (Legal Business Name): CLC OF BRUCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 11/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 HWY 9 SOUTH
BRUCE MS
38915
US

IV. Provider business mailing address

PO BOX 1280
BRUCE MS
38915-1280
US

V. Phone/Fax

Practice location:
  • Phone: 662-412-5100
  • Fax: 662-412-5122
Mailing address:
  • Phone: 662-412-5100
  • Fax: 662-412-5122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number667
License Number StateMS

VIII. Authorized Official

Name: MR. DOUGLAS M WRIGHT JR.
Title or Position: MANAGING MEMBER
Credential:
Phone: 662-680-3148