Provider Demographics
NPI:1225086374
Name:COMMUNITY CARE CENTER OF VICKSBURG LLC
Entity Type:Organization
Organization Name:COMMUNITY CARE CENTER OF VICKSBURG LLC
Other - Org Name:HERITAGE HOUSE NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMIN. ASST.
Authorized Official - Prefix:MRS
Authorized Official - First Name:TONI
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-709-1408
Mailing Address - Street 1:3103 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-4825
Mailing Address - Country:US
Mailing Address - Phone:601-638-1514
Mailing Address - Fax:601-638-8738
Practice Address - Street 1:3103 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-4825
Practice Address - Country:US
Practice Address - Phone:601-638-1514
Practice Address - Fax:601-638-8738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS54314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS80405OtherBLUE CROSS BLUE SHIELD
MS00230137Medicaid
MS255284Medicare Oscar/Certification