Basic Information
| Provider Information | |||||||||
| NPI: | 1326197211 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COTTAGE GROVE NURSING HOME, LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1116 FOREST AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392063216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013666461 | ||||||||
| FaxNumber: | 6013624041 | ||||||||
| Practice Location | |||||||||
| Address1: | 1116 FOREST AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392063216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013666461 | ||||||||
| FaxNumber: | 6013624041 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 03/26/2013 | ||||||||
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| AuthorizedOfficialLastName: | CLEVELAND | ||||||||
| AuthorizedOfficialFirstName: | JUADINE | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6013666461 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 326 | MS | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 00023040 | 05 | MS | MEDICAID |