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General NPI Number Information
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NPI Number | 1306031372
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Entity Type | Organization
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Legal Business Name | WISTERIA GARDENS, LLC
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Dates
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Enumeration Date | 09/12/2007
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Last Update Date | 09/12/2007
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Provider Practice Location Address
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Address Line | 5420 HIGHWAY 80 E
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City | PEARL
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State | MS
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Zip | 39208-8924
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Country | US
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Telephone | 601-988-6800
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Fax |
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Provider Business Mailing Address
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Address Line | 5420 HIGHWAY 80 E
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City | PEARL
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State | MS
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Zip | 39208-8924
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Country | US
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Telephone | 601-988-6800
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | WILLIAM D HILL JR.
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Credential |
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Telephone | 601-988-6800
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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 |
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License Number State |
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