MEDICARE: COPIAH COMMUNITY CARE CENTER 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	949	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
2	80413	OTHER	MS	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1720036916
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COPIAH COMMUNITY CARE CENTER LLC

Provider Business Mailing Address
First Line	:	806 W GEORGETOWN ST
Second Line	:
City	:	CRYSTAL SPRINGS
State	:	MS
Zip	:	39059-9453
Country	:	US
Telephone Number	:	601-892-1881
Fax Number	:	601-892-1985

Provider Business Practice Location Address
First Line	:	806 W GEORGETOWN ST
Second Line	:
City	:	CRYSTAL SPRINGS
State	:	MS
Zip	:	39059-9453
Country	:	US
Telephone Number	:	601-892-1881
Fax Number	:	601-892-1985

Authorized Official
Title or Position	:	AUTHORIZED REPRESENTATIVE
Name	:	MRS. TONI PARKINSON
Credential	:
Telephone Number	:	601-709-1408

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	04/30/2013

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