Provider Demographics
NPI:1497737571
Name:BEDFORD CARE CENTER OF MENDENHALL, LLC
Entity Type:Organization
Organization Name:BEDFORD CARE CENTER OF MENDENHALL, 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 1:925 MANGUM AVE
Practice Address - Street 2:
Practice Address - City:MENDENHALL
Practice Address - State:MS
Practice Address - Zip Code:39114-3026
Practice Address - Country:US
Practice Address - Phone:601-847-1311
Practice Address - Fax:601-847-0857
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
MS600314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230157Medicaid
MS000080357OtherBCBS PROVIDER NUMBER
MS4594930001Medicare NSC
MS000080357OtherBCBS PROVIDER NUMBER