Provider Demographics
NPI:1063628451
Name:COMMUNITY CARE CENTER OF ABERDEEN
Entity Type:Organization
Organization Name:COMMUNITY CARE CENTER OF ABERDEEN
Other - Org Name:CARE CENTER OF ABERDEEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER REPRESENTATIVE
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:STALLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-956-8884
Mailing Address - Street 1:505 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:MS
Mailing Address - Zip Code:39730-3349
Mailing Address - Country:US
Mailing Address - Phone:662-369-6431
Mailing Address - Fax:662-369-6473
Practice Address - Street 1:505 JACKSON ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MS
Practice Address - Zip Code:39730-3349
Practice Address - Country:US
Practice Address - Phone:662-369-6431
Practice Address - Fax:662-369-6473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS561314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230034Medicaid
MS255097Medicare Oscar/Certification