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General NPI Number Information
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NPI Number | 1538719125
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Entity Type | Organization
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Legal Business Name | MOCKINGBIRD ASSISTED LIVING, LLC
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Dates
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Enumeration Date | 09/16/2019
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Last Update Date | 09/16/2019
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Provider Practice Location Address
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Address Line | 1101 W CHAMBERS DR
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City | BOONEVILLE
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State | MS
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Zip | 38829-6840
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Country | US
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Telephone | 662-416-5469
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Fax | 662-596-3052
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Provider Business Mailing Address
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Address Line | 1101 W CHAMBERS DR
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City | BOONEVILLE
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State | MS
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Zip | 38829-6840
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Country | US
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Telephone | 662-416-5469
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Fax | 662-596-3052
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. RONALD JOE GROOMS
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Credential |
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Telephone | 662-596-3030
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State |
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