Basic Information
| Provider Information | |||||||||
| NPI: | 1366584708 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HATTIESBURG CONVALESCENT HOME, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HATTIESBURG CONVALESCENT CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 514 BAY ST | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394013933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015444230 | ||||||||
| FaxNumber: | 6015822480 | ||||||||
| Practice Location | |||||||||
| Address1: | 514 BAY ST | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394013933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015444230 | ||||||||
| FaxNumber: | 6015822480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCMAHAN | ||||||||
| AuthorizedOfficialFirstName: | JEWELL | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6015444230 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 0017704.1 | MS | X | 193200000X MULTI-SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist | 314000000X | 25 | MS | X | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0023061 | 05 | MS | MEDICAID | 00036421 | 05 | MS | MEDICAID |