Healthcare Provider Details

I. General information

NPI: 1962508119
Provider Name (Legal Business Name): SENTRY-GAUTIER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 02/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5090 GAUTIER VANCLEAVE ROAD
GAUTIER MS
39553
US

IV. Provider business mailing address

106A OFFICE PARK DRIVE
BRANDON MS
39042
US

V. Phone/Fax

Practice location:
  • Phone: 228-522-6700
  • Fax: 228-522-3383
Mailing address:
  • Phone: 601-824-9010
  • Fax: 601-824-9044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number956
License Number StateMS

VIII. Authorized Official

Name: MR. CAMERON DIRK GODDARD
Title or Position: AR MANAGER
Credential:
Phone: 601-824-9010