Provider Demographics
NPI:1497703755
Name:WASHINGTON CARE CENTER, LLC
Entity Type:Organization
Organization Name:WASHINGTON CARE CENTER, LLC
Other - Org Name:WASHINGTON CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:BELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-709-1408
Mailing Address - Street 1:1620 LISA DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703
Mailing Address - Country:US
Mailing Address - Phone:662-335-2897
Mailing Address - Fax:662-335-2130
Practice Address - Street 1:1620 LISA DRIVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703
Practice Address - Country:US
Practice Address - Phone:662-335-2897
Practice Address - Fax:662-335-2130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS989314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS80454OtherBLUE CROSS BLUE SHIELD
MS04003561Medicaid
MS04003561Medicaid