Healthcare Provider Details

I. General information

NPI: 1891869012
Provider Name (Legal Business Name): VCNCL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 02/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 5TH ST N
COLUMBUS MS
39705-2208
US

IV. Provider business mailing address

PO BOX 2712
RIDGELAND MS
39158-2712
US

V. Phone/Fax

Practice location:
  • Phone: 662-328-1133
  • Fax: 662-328-0774
Mailing address:
  • Phone: 601-853-2667
  • Fax: 601-853-2116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number183
License Number StateMS

VIII. Authorized Official

Name: MR. DAVID ROTOLO
Title or Position: MEMBER
Credential:
Phone: 601-853-2667