Healthcare Provider Details

I. General information

NPI: 1326178203
Provider Name (Legal Business Name): SMITH COUNTY LTC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 MAGNOLIA DRIVE
RALEIGH MS
39153
US

IV. Provider business mailing address

309 MAGNOLIA DRIVE P. O. BOX 128
RALEIGH MS
39153
US

V. Phone/Fax

Practice location:
  • Phone: 601-782-4244
  • Fax: 601-782-9616
Mailing address:
  • Phone: 601-782-4244
  • Fax: 601-782-9616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number354
License Number StateMS

VIII. Authorized Official

Name: MRS. TONYA NELL EUBANKS
Title or Position: CONTROLLER
Credential: CONTROLLER
Phone: 662-234-1520