Provider Demographics
NPI:1568791804
Name:NORTH STREET HEALTHCARE LLC
Entity Type:Organization
Organization Name:NORTH STREET HEALTHCARE LLC
Other - Org Name:COMPERES NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-304-0980
Mailing Address - Street 1:323 HIGHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-4635
Mailing Address - Country:US
Mailing Address - Phone:601-304-0980
Mailing Address - Fax:601-304-1155
Practice Address - Street 1:865 NORTH ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-3020
Practice Address - Country:US
Practice Address - Phone:601-948-6531
Practice Address - Fax:601-948-6166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-16
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAPPLING FOR314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230016Medicaid
MS25-5249Medicare UPIN