Healthcare Provider Details

I. General information

NPI: 1609866235
Provider Name (Legal Business Name): KEMPER COUNTY LTC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 WILLOW AVE
DEKALB MS
39328-0577
US

IV. Provider business mailing address

PO BOX 577
DE KALB MS
39328-0577
US

V. Phone/Fax

Practice location:
  • Phone: 601-743-5888
  • Fax: 601-743-4506
Mailing address:
  • Phone: 601-743-5888
  • Fax: 601-743-4506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number358
License Number StateMS

VIII. Authorized Official

Name: MRS. PATTY C NESTER
Title or Position: ADMINISTRATOR
Credential: NHA
Phone: 601-743-5888