Provider Demographics
NPI:1336136241
Name:DUGAN MEMORIAL HOME
Entity Type:Organization
Organization Name:DUGAN MEMORIAL HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:SHEA
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:662-494-3640
Mailing Address - Street 1:PO BOX 698
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39773-0698
Mailing Address - Country:US
Mailing Address - Phone:662-494-3640
Mailing Address - Fax:662-494-3641
Practice Address - Street 1:804 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:MS
Practice Address - Zip Code:39773-3137
Practice Address - Country:US
Practice Address - Phone:662-494-3640
Practice Address - Fax:662-494-3641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS178314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS25A411Medicaid
MS25-5313Medicare ID - Type Unspecified