Healthcare Provider Details

I. General information

NPI: 1912997685
Provider Name (Legal Business Name): CLC OF LIBERTY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 INDUSTRIAL PARK
LIBERTY MS
39645-8069
US

IV. Provider business mailing address

323 INDUSTRIAL PARK
LIBERTY MS
39645-8069
US

V. Phone/Fax

Practice location:
  • Phone: 601-657-1000
  • Fax: 601-657-1008
Mailing address:
  • Phone: 601-657-1000
  • Fax: 601-657-1008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number930
License Number StateMS

VIII. Authorized Official

Name: MR. DOUGLAS M. WRIGHT JR.
Title or Position: MANAGING MEMBER
Credential:
Phone: 662-680-3148