=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245663251
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | METHODIST HOME ROAD LIVING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2013
-----------------------------------------------------
Last Update Date | 08/13/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4560 METHODIST HOME ROAD
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 769-257-7232
-----------------------------------------------------
Fax | 769-257-7745
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4560 METHODIST HOME ROAD
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 769-257-7232
-----------------------------------------------------
Fax | 769-257-7745
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER/OWNER
-----------------------------------------------------
Name | MRS. PEBLES JONES-WRIGHT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 769-257-7232
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | P321453
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------