Healthcare Provider Details

I. General information

NPI: 1184613143
Provider Name (Legal Business Name): SHADY LAWN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 05/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 SHADY LAWN PL
VICKSBURG MS
39180
US

IV. Provider business mailing address

9020 OVERLOOK BLVD STE 202
BRENTWOOD TN
37027-2755
US

V. Phone/Fax

Practice location:
  • Phone: 601-636-1448
  • Fax: 601-636-8811
Mailing address:
  • Phone: 615-250-7100
  • Fax: 615-250-7101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number182
License Number StateMS

VIII. Authorized Official

Name: MR. WILLIAM D. ORAND
Title or Position: CEO
Credential:
Phone: 615-250-7100