=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285442137
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 627 MIDDLETON ROAD OPCO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/24/2024
-----------------------------------------------------
Last Update Date | 03/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 627 MIDDLETON RD
-----------------------------------------------------
City | WINONA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38967-2021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-283-1260
-----------------------------------------------------
Fax | 662-283-4704
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 627 MIDDLETON RD
-----------------------------------------------------
City | WINONA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38967-2021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-283-1260
-----------------------------------------------------
Fax | 662-283-4704
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | TIFFANY HOBACK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-698-9040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------