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General NPI Number Information
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NPI Number | 1235111311
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Entity Type | Organization
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Legal Business Name | BEDFORD CARE CENTER OF PETAL, LLC
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Dates
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Enumeration Date | 11/15/2005
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Last Update Date | 01/15/2010
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Provider Practice Location Address
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Address Line | 908 SOUTH GEORGE STREET
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City | PETAL
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State | MS
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Zip | 39465-2014
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Country | US
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Telephone | 601-544-7441
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Fax | 601-582-3217
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Provider Business Mailing Address
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Address Line | 100 W PINE ST
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City | HATTIESBURG
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State | MS
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Zip | 39401-3467
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Country | US
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Telephone | 601-583-3232
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Fax | 601-582-7539
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Authorized Official
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Title or Position | CONTROLLER
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Name | MR. STEPHEN A. WORREL
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Credential |
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Telephone | 601-583-3232
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 140
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License Number State | MS
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