Provider Demographics
NPI:1508991357
Name:SAMARITAN GARDEN PERSONAL CARE HOME
Entity Type:Organization
Organization Name:SAMARITAN GARDEN PERSONAL CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:PULLIAM
Authorized Official - Last Name:SATTERWHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-566-9974
Mailing Address - Street 1:2603 S GLOSTER ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6903
Mailing Address - Country:US
Mailing Address - Phone:662-566-9974
Mailing Address - Fax:
Practice Address - Street 1:2603 S GLOSTER ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6903
Practice Address - Country:US
Practice Address - Phone:662-566-9974
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS876310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770422Medicaid