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General NPI Number Information
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NPI Number | 1740668755
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Entity Type | Organization
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Legal Business Name | BROADWAY MANOR LIMITED LIABILITY
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Dates
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Enumeration Date | 05/11/2015
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Last Update Date | 07/24/2015
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Provider Practice Location Address
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Address Line | 446 N BROADWAY STREET
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City | GREENVILLE
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State | MS
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Zip | 38701-2552
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Country | US
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Telephone | 662-702-5007
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Fax |
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Provider Business Mailing Address
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Address Line | 515 N BROADWAY ST
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City | GREENVILLE
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State | MS
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Zip | 38701-2552
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Country | US
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Telephone | 662-702-5007
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MS. JMELBA H THOMPSON
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Credential |
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Telephone | 662-702-5007
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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 | 1096
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License Number State | MS
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