Healthcare Provider Details

I. General information

NPI: 1326197211
Provider Name (Legal Business Name): COTTAGE GROVE NURSING HOME, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 03/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 FOREST AVE
JACKSON MS
39206-3216
US

IV. Provider business mailing address

1116 FOREST AVE
JACKSON MS
39206-3216
US

V. Phone/Fax

Practice location:
  • Phone: 601-366-6461
  • Fax: 601-362-4041
Mailing address:
  • Phone: 601-366-6461
  • Fax: 601-362-4041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number326
License Number StateMS

VIII. Authorized Official

Name: MS. JUADINE B CLEVELAND
Title or Position: ADMINISTRATOR
Credential:
Phone: 601-366-6461