Provider Demographics
NPI:1518094358
Name:COMMUNITY CARE CENTER OF LAUREL, LLC
Entity Type:Organization
Organization Name:COMMUNITY CARE CENTER OF LAUREL, LLC
Other - Org Name:CARE CENTER OF LAUREL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER REPRESENTATIVE
Authorized Official - Prefix:MS
Authorized Official - First Name:TONI
Authorized Official - Middle Name:H
Authorized Official - Last Name:PARKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-709-1408
Mailing Address - Street 1:935 WEST DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-4703
Mailing Address - Country:US
Mailing Address - Phone:601-649-8006
Mailing Address - Fax:601-426-6366
Practice Address - Street 1:935 WEST DR
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4703
Practice Address - Country:US
Practice Address - Phone:601-649-8006
Practice Address - Fax:601-426-6366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS564314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230035Medicaid
MS00230035Medicaid