Healthcare Provider Details

I. General information

NPI: 1437967536
Provider Name (Legal Business Name): 501 SOUTH LOCUST STREET OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2024
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S LOCUST ST
MCCOMB MS
39648-4336
US

IV. Provider business mailing address

501 S LOCUST ST
MCCOMB MS
39648-4336
US

V. Phone/Fax

Practice location:
  • Phone: 601-684-8111
  • Fax:
Mailing address:
  • Phone: 601-684-8111
  • Fax: 601-684-2881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: TIFFANY HOBACK
Title or Position: MANAGER
Credential:
Phone: 770-698-9040