MEDICARE: CLC OF LAUREL, 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	197	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326038092
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLC OF LAUREL, LLC

Provider Business Mailing Address
First Line	:	1036 WEST DR
Second Line	:
City	:	LAUREL
State	:	MS
Zip	:	39440-4706
Country	:	US
Telephone Number	:	601-425-3191
Fax Number	:	601-428-1164

Provider Business Practice Location Address
First Line	:	1036 WEST DR
Second Line	:
City	:	LAUREL
State	:	MS
Zip	:	39440-4706
Country	:	US
Telephone Number	:	601-425-3191
Fax Number	:	601-428-1164

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MR. DOUGLAS M. WRIGHT JR.
Credential	:
Telephone Number	:	662-680-3148

Provider Enumeration Date	:	10/25/2005
Last Update Date	:	01/28/2008

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Directions to “CLC OF LAUREL, LLC ” Practice Location

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