Healthcare Provider Details

I. General information

NPI: 1205961810
Provider Name (Legal Business Name): DYNAMIC COLUMBIA OPERATING COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 NORTH MAIN STREET
COLUMBIA MS
39429-2070
US

IV. Provider business mailing address

1506 NORTH MAIN STREET
COLUMBIA MS
39429-2070
US

V. Phone/Fax

Practice location:
  • Phone: 601-736-9557
  • Fax: 601-736-9903
Mailing address:
  • Phone: 601-736-9557
  • Fax: 601-736-9903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number507
License Number StateMS

VIII. Authorized Official

Name: MRS. SHIRLEY S BROWN
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 601-736-9557