Provider Demographics
NPI:1548244262
Name:WILKINSON COUNTY NURSING CENTER LLC
Entity Type:Organization
Organization Name:WILKINSON COUNTY NURSING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-304-0980
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:166 S LAFAYETTE ST
Mailing Address - City:CENTREVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39631-0310
Mailing Address - Country:US
Mailing Address - Phone:601-645-5253
Mailing Address - Fax:601-645-6389
Practice Address - Street 1:166 S LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MS
Practice Address - Zip Code:39631-0310
Practice Address - Country:US
Practice Address - Phone:601-645-5253
Practice Address - Fax:601-645-6389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS379314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230138Medicaid
MS00230138Medicaid