Provider Demographics
NPI:1548210289
Name:COVENANT HEALTH & REHAB OF VICKSBURG, LP
Entity Type:Organization
Organization Name:COVENANT HEALTH & REHAB OF VICKSBURG, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:ULLERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-937-7994
Mailing Address - Street 1:2850 PORTERS CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-1805
Mailing Address - Country:US
Mailing Address - Phone:601-638-9211
Mailing Address - Fax:601-636-4986
Practice Address - Street 1:2850 PORTERS CHAPEL RD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-1805
Practice Address - Country:US
Practice Address - Phone:601-638-9211
Practice Address - Fax:601-636-4986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS595314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0220282Medicaid
MS25-5140Medicare ID - Type Unspecified