Healthcare Provider Details

I. General information

NPI: 1578553459
Provider Name (Legal Business Name): VICKSBURG CONVALESCENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

1708 CHERRY ST
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: 601-638-3632
  • Fax: 601-638-3998
Mailing address:
  • Phone: 615-250-7100
  • Fax: 615-250-7102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number176
License Number StateMS

VIII. Authorized Official

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