Healthcare Provider Details

I. General information

NPI: 1225012941
Provider Name (Legal Business Name): CLAIBORNE COUNTY NURSING CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2124 OLD HIGHWAY 61 S
PORT GIBSON MS
39150-2589
US

IV. Provider business mailing address

PO BOX 1018 2124 OLD HWY 61 SOUTH
PORT GIBSON MS
39150-1018
US

V. Phone/Fax

Practice location:
  • Phone: 601-437-8737
  • Fax: 601-437-8724
Mailing address:
  • Phone: 601-437-8737
  • Fax: 601-437-8724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number679
License Number StateMS

VIII. Authorized Official

Name: MRS. TINA L ELLIS
Title or Position: COMPTROLLER
Credential:
Phone: 601-304-0980