Healthcare Provider Details

I. General information

NPI: 1750431391
Provider Name (Legal Business Name): MADISON COUNTY NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 03/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421A E PEACE ST
CANTON MS
39046-4938
US

IV. Provider business mailing address

1421A E PEACE ST P.O. BOX 488
CANTON MS
39046-4938
US

V. Phone/Fax

Practice location:
  • Phone: 601-855-5760
  • Fax:
Mailing address:
  • Phone: 601-855-5760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number187
License Number StateMS

VIII. Authorized Official

Name: MR. DANIEL LOGAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 601-855-5771