Healthcare Provider Details

I. General information

NPI: 1124776232
Provider Name (Legal Business Name): 538 MENGE AVENUE OPERATIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2022
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

538 MENGE AVE
PASS CHRISTIAN MS
39571-4234
US

IV. Provider business mailing address

538 MENGE AVE
PASS CHRISTIAN MS
39571-4234
US

V. Phone/Fax

Practice location:
  • Phone: 228-452-4344
  • Fax: 228-452-2264
Mailing address:
  • Phone: 228-452-4344
  • Fax: 228-452-2264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: TIM LEHNER
Title or Position: MANAGER
Credential:
Phone: 770-698-9040