Basic Information
| Provider Information | |||||||||
| NPI: | 1598716193 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GGNSC BROOKHAVEN LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GOLDEN LIVINGCENTER - BROOK MANOR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 519 BROOKMAN DR | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396012326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628422461 | ||||||||
| FaxNumber: | 6628412884 | ||||||||
| Practice Location | |||||||||
| Address1: | 519 BROOKMAN DR | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396012326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628422461 | ||||||||
| FaxNumber: | 6628412884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 07/16/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RASMUSSEN-JONES | ||||||||
| AuthorizedOfficialFirstName: | HOLLY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 4792014835 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 377 | MS | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 23021 | 05 | MS | MEDICAID |