Healthcare Provider Details

I. General information

NPI: 1568791804
Provider Name (Legal Business Name): NORTH STREET HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2009
Last Update Date: 12/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

865 NORTH ST
JACKSON MS
39202-3020
US

IV. Provider business mailing address

323 HIGHLAND BLVD
NATCHEZ MS
39120-4635
US

V. Phone/Fax

Practice location:
  • Phone: 601-948-6531
  • Fax: 601-948-6166
Mailing address:
  • Phone: 601-304-0980
  • Fax: 601-304-1155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. CHARLES BRUCE KELLY
Title or Position: MANAGING MEMBER
Credential:
Phone: 601-304-0980