Provider Demographics
NPI:1144499245
Name:MARTHA COKER HOME, INC.
Entity type:Organization
Organization Name:MARTHA COKER HOME, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCALILLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-844-8977
Mailing Address - Street 1:PO BOX 1567
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38802-1567
Mailing Address - Country:US
Mailing Address - Phone:662-844-8977
Mailing Address - Fax:662-690-6643
Practice Address - Street 1:2041 GRAND AVENUE
Practice Address - Street 2:
Practice Address - City:YAZOO CITY
Practice Address - State:MS
Practice Address - Zip Code:39194
Practice Address - Country:US
Practice Address - Phone:662-844-8977
Practice Address - Fax:662-690-6643
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSISSIPPI METHODIST SENIOR SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-22
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS152314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08107516Medicaid
MS255327Medicare Oscar/Certification