Healthcare Provider Details

I. General information

NPI: 1518159862
Provider Name (Legal Business Name): BELHAVEN SENIOR CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2007
Last Update Date: 10/04/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 KELLY BLVD
MADISON MS
39110
US

IV. Provider business mailing address

111 KELLY BLVD
MADISON MS
39110
US

V. Phone/Fax

Practice location:
  • Phone: 601-898-6080
  • Fax: 601-898-6348
Mailing address:
  • Phone: 601-898-6080
  • Fax: 601-898-6348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number624
License Number StateMS

VIII. Authorized Official

Name: MATTHEW CORLEY WAGNER
Title or Position: ADMINISTRATOR
Credential: LNHA
Phone: 601-898-6080