Healthcare Provider Details

I. General information

NPI: 1235111311
Provider Name (Legal Business Name): BEDFORD CARE CENTER OF PETAL, 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

908 SOUTH GEORGE STREET
PETAL MS
39465-2014
US

IV. Provider business mailing address

100 W PINE ST
HATTIESBURG MS
39401-3467
US

V. Phone/Fax

Practice location:
  • Phone: 601-544-7441
  • Fax: 601-582-3217
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 Number140
License Number StateMS

VIII. Authorized Official

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