Healthcare Provider Details

I. General information

NPI: 1477501922
Provider Name (Legal Business Name): COMMUNITY CARE CENTER OF GRENADA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 04/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 GRANDVIEW DRIVE
GRENADA MS
38901-1674
US

IV. Provider business mailing address

1950 GRANDVIEW DRIVE
GRENADA MS
38901-1674
US

V. Phone/Fax

Practice location:
  • Phone: 662-226-9554
  • Fax: 662-226-5537
Mailing address:
  • Phone: 662-226-9554
  • Fax: 662-226-5537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number413
License Number StateMS

VIII. Authorized Official

Name: MRS. TONI PARKINSON
Title or Position: AUTHORIZED REPRESENTATIVE
Credential:
Phone: 601-709-1408