Healthcare Provider Details

I. General information

NPI: 1306031372
Provider Name (Legal Business Name): WISTERIA GARDENS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 09/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5420 HIGHWAY 80 E
PEARL MS
39208-8924
US

IV. Provider business mailing address

5420 HIGHWAY 80 E
PEARL MS
39208-8924
US

V. Phone/Fax

Practice location:
  • Phone: 601-988-6800
  • Fax:
Mailing address:
  • Phone: 601-988-6800
  • Fax:

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: WILLIAM D HILL JR.
Title or Position: ADMINISTRATOR
Credential:
Phone: 601-988-6800