MEDICARE: COTTAGE GROVE NURSING HOME, LP

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	326	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	:	1326197211
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COTTAGE GROVE NURSING HOME, LP

Provider Business Mailing Address
First Line	:	1116 FOREST AVE
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39206-3216
Country	:	US
Telephone Number	:	601-366-6461
Fax Number	:	601-362-4041

Provider Business Practice Location Address
First Line	:	1116 FOREST AVE
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39206-3216
Country	:	US
Telephone Number	:	601-366-6461
Fax Number	:	601-362-4041

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. JUADINE B CLEVELAND
Credential	:
Telephone Number	:	601-366-6461

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	03/26/2013

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