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NPI Code Detail

MEDICARE: CLC OF IUKA, LLC

MEDICARE: CLC OF IUKA, 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
1314000000XSkilled Nursing Facility643MS

Other Identifiers

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

General Provider Information

NPI Number : 1457341976
Entity Type Code : Organization
Provider Name (Legal Business Name) : CLC OF IUKA, LLC
Provider Business Mailing Address
First Line : PO BOX 562
Second Line :
City : IUKA
State : MS
Zip : 38852-0562
Country : US
Telephone Number : 662-423-3422
Fax Number : 662-423-5259
Provider Business Practice Location Address
First Line : 1410 W QUITMAN ST
Second Line :
City : IUKA
State : MS
Zip : 38852-1129
Country : US
Telephone Number : 662-423-3422
Fax Number : 662-423-5259
Authorized Official
Title or Position : MANAGING MEMBER
Name : MR. DOUGLAS M. WRIGHT JR.
Credential :
Telephone Number : 662-680-3148
Provider Enumeration Date : 10/26/2005
Last Update Date : 01/28/2008

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Directions to “CLC OF IUKA, LLC ” Practice Location

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