Healthcare Provider Details

I. General information

NPI: 1548420086
Provider Name (Legal Business Name): MS GREENBOUGH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 10/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 DESOTO AVENUE EXT
CLARKSDALE MS
38614-2814
US

IV. Provider business mailing address

40 PALAFOX PL SUITE 400
PENSACOLA FL
32502-5697
US

V. Phone/Fax

Practice location:
  • Phone: 662-627-3486
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: JAMES RICHARDSON
Title or Position: PRESIDENT
Credential:
Phone: 850-430-0000