Healthcare Provider Details

I. General information

NPI: 1134360753
Provider Name (Legal Business Name): CLINTON HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2009
Last Update Date: 03/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 PINEHAVEN RD
CLINTON MS
39056-3455
US

IV. Provider business mailing address

1251 PINEHAVEN RD
CLINTON MS
39056-3455
US

V. Phone/Fax

Practice location:
  • Phone: 601-924-2996
  • Fax: 601-924-6447
Mailing address:
  • Phone: 601-924-2996
  • Fax: 601-924-6447

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: MRS. TINA LOUISE ELLIS
Title or Position: COMPTROLLER
Credential:
Phone: 601-304-0980