Healthcare Provider Details

I. General information

NPI: 1548210289
Provider Name (Legal Business Name): COVENANT HEALTH & REHAB OF VICKSBURG, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 08/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 PORTERS CHAPEL RD
VICKSBURG MS
39180-1805
US

IV. Provider business mailing address

2850 PORTERS CHAPEL RD
VICKSBURG MS
39180-1805
US

V. Phone/Fax

Practice location:
  • Phone: 601-638-9211
  • Fax: 601-636-4986
Mailing address:
  • Phone: 601-638-9211
  • Fax: 601-636-4986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number595
License Number StateMS

VIII. Authorized Official

Name: MRS. JUDY ULLERY
Title or Position: PRESIDENT
Credential:
Phone: 901-937-7994