Healthcare Provider Details

I. General information

NPI: 1285442137
Provider Name (Legal Business Name): 627 MIDDLETON ROAD OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2024
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 MIDDLETON RD
WINONA MS
38967-2021
US

IV. Provider business mailing address

627 MIDDLETON RD
WINONA MS
38967-2021
US

V. Phone/Fax

Practice location:
  • Phone: 662-283-1260
  • Fax: 662-283-4704
Mailing address:
  • Phone: 662-283-1260
  • Fax: 662-283-4704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY HOBACK
Title or Position: MANAGER
Credential:
Phone: 770-698-9040