Healthcare Provider Details

I. General information

NPI: 1497737571
Provider Name (Legal Business Name): BEDFORD CARE CENTER OF MENDENHALL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 01/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 MANGUM AVE
MENDENHALL MS
39114-3026
US

IV. Provider business mailing address

100 W PINE ST
HATTIESBURG MS
39401-3467
US

V. Phone/Fax

Practice location:
  • Phone: 601-847-1311
  • Fax: 601-847-0857
Mailing address:
  • Phone: 601-583-3232
  • Fax: 601-582-7539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number600
License Number StateMS

VIII. Authorized Official

Name: MR. STEPHEN A. WORREL
Title or Position: CONTROLLER
Credential:
Phone: 601-583-3232