MEDICARE: MAJESTIC ESTATES 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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility		MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1029044	OTHER	MS	STATE ID

General Provider Information

NPI Number	:	1932525714
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAJESTIC ESTATES LLC.

Provider Business Mailing Address
First Line	:	PO BOX 1442
Second Line	:
City	:	FOREST
State	:	MS
Zip	:	39074-0442
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	511 N BROAD ST
Second Line	:
City	:	FOREST
State	:	MS
Zip	:	39074-3511
Country	:	US
Telephone Number	:	601-405-2116
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PHAREN NELSON
Credential	:
Telephone Number	:	601-405-2116

Provider Enumeration Date	:	03/17/2014
Last Update Date	:	03/17/2014

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Directions to “MAJESTIC ESTATES LLC. ” Practice Location

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