Healthcare Provider Details

I. General information

NPI: 1194773515
Provider Name (Legal Business Name): TISHOMINGO COMMUNITY CARE CENTER 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

230 KAKI AVE
IUKA MS
38852-1192
US

IV. Provider business mailing address

230 KAKI AVE
IUKA MS
38852-1192
US

V. Phone/Fax

Practice location:
  • Phone: 662-423-9112
  • Fax: 662-423-9121
Mailing address:
  • Phone: 662-423-9112
  • Fax: 662-423-9121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number414
License Number StateMS

VIII. Authorized Official

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