Provider Demographics
NPI:1326197211
Name:COTTAGE GROVE NURSING HOME, LP
Entity Type:Organization
Organization Name:COTTAGE GROVE NURSING HOME, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JUADINE
Authorized Official - Middle Name:B
Authorized Official - Last Name:CLEVELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-366-6461
Mailing Address - Street 1:1116 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-3216
Mailing Address - Country:US
Mailing Address - Phone:601-366-6461
Mailing Address - Fax:601-362-4041
Practice Address - Street 1:1116 FOREST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-3216
Practice Address - Country:US
Practice Address - Phone:601-366-6461
Practice Address - Fax:601-362-4041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS326314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00023040Medicaid