Provider Demographics
NPI:1447240122
Name:CLC OF BOONEVILLE, LLC
Entity Type:Organization
Organization Name:CLC OF BOONEVILLE, LLC
Other - Org Name:LONGWOOD COMMUNITY LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:662-680-3148
Mailing Address - Street 1:200 LONG ST
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-4306
Mailing Address - Country:US
Mailing Address - Phone:662-728-6234
Mailing Address - Fax:662-728-6944
Practice Address - Street 1:200 LONG ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-4306
Practice Address - Country:US
Practice Address - Phone:662-728-6234
Practice Address - Fax:662-728-6944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS155314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0230175Medicaid
MS25-5264Medicare ID - Type Unspecified