Provider Demographics
NPI:1225086648
Name:PERRY COMMUNITY CARE CENTER LLC
Entity Type:Organization
Organization Name:PERRY COMMUNITY CARE CENTER LLC
Other - Org Name:PERRY COUNTY NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
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 1:202 BAY AVE
Mailing Address - Street 2:
Mailing Address - City:RICHTON
Mailing Address - State:MS
Mailing Address - Zip Code:39476-2941
Mailing Address - Country:US
Mailing Address - Phone:601-788-2490
Mailing Address - Fax:601-788-2499
Practice Address - Street 1:202 BAY AVE
Practice Address - Street 2:
Practice Address - City:RICHTON
Practice Address - State:MS
Practice Address - Zip Code:39476-2941
Practice Address - Country:US
Practice Address - Phone:601-788-2490
Practice Address - Fax:601-788-2499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS650314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS80115OtherBLUE CROSS BLUE SHIELD
MS00230159Medicaid
MS80115OtherBLUE CROSS BLUE SHIELD