Provider Demographics
NPI:1235111311
Name:BEDFORD CARE CENTER OF PETAL, LLC
Entity Type:Organization
Organization Name:BEDFORD CARE CENTER OF PETAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WORREL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-583-3232
Mailing Address - Street 1:100 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-3467
Mailing Address - Country:US
Mailing Address - Phone:601-583-3232
Mailing Address - Fax:601-582-7539
Practice Address - Street 1:908 SOUTH GEORGE STREET
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-2014
Practice Address - Country:US
Practice Address - Phone:601-544-7441
Practice Address - Fax:601-582-3217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS140314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230155Medicaid
MS000080355OtherBCBS PROVIDER NUMBER
MS00230155Medicaid
MS255149Medicare Oscar/Certification