Basic Information
| Provider Information | |||||||||
| NPI: | 1548334642 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TUPELO NURSING AND REHABILITATION CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 428 | ||||||||
| Address2: | |||||||||
| City: | ORCHARD PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141270428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166624955 | ||||||||
| FaxNumber: | 7166679230 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 BRIAR RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388045903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628440675 | ||||||||
| FaxNumber: | 6628426838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 11/13/2012 | ||||||||
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| AuthorizedOfficialLastName: | BENNETT | ||||||||
| AuthorizedOfficialFirstName: | NORBERT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CO-CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7166624955 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 416 | MS | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 000080432 | 01 | MS | BC BS OF MISSISSIPPI | OTHER | 01077271 | 05 | MS | MEDICAID |