Healthcare Provider Details

I. General information

NPI: 1225086648
Provider Name (Legal Business Name): PERRY COMMUNITY CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 10/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 BAY AVE
RICHTON MS
39476-2941
US

IV. Provider business mailing address

202 BAY AVE
RICHTON MS
39476-2941
US

V. Phone/Fax

Practice location:
  • Phone: 601-788-2490
  • Fax: 601-788-2499
Mailing address:
  • Phone: 601-788-2490
  • Fax: 601-788-2499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number650
License Number StateMS

VIII. Authorized Official

Name: MRS. TONI PARKINSON
Title or Position: AUTHORIZED REPRESENTATIVE
Credential:
Phone: 601-709-1408