MEDICARE: CLAIBORNE COUNTY SENIOR CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	679	MS

General Provider Information

NPI Number	:	1154513414
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLAIBORNE COUNTY SENIOR CARE LLC

Provider Business Mailing Address
First Line	:	2124 OLD HIGHWAY 61 S
Second Line	:	P O BOX 1018
City	:	PORT GIBSON
State	:	MS
Zip	:	39150-2589
Country	:	US
Telephone Number	:	601-437-8737
Fax Number	:	601-437-8724

Provider Business Practice Location Address
First Line	:	2124 OLD HIGHWAY 61 S
Second Line	:
City	:	PORT GIBSON
State	:	MS
Zip	:	39150-2589
Country	:	US
Telephone Number	:	601-437-8737
Fax Number	:	601-437-8724

Authorized Official
Title or Position	:	COMPTROLLER
Name	:	MRS. TINA ELLIS
Credential	:
Telephone Number	:	601-304-0980

Provider Enumeration Date	:	08/10/2007
Last Update Date	:	08/10/2007

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