Provider Demographics
NPI:1578553459
Name:VICKSBURG CONVALESCENT, LLC
Entity Type:Organization
Organization Name:VICKSBURG CONVALESCENT, LLC
Other - Org Name:VICKSBURG CONVALESCENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:ORAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-250-7100
Mailing Address - Street 1:9020 OVERLOOK BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2755
Mailing Address - Country:US
Mailing Address - Phone:615-250-7100
Mailing Address - Fax:615-250-7102
Practice Address - Street 1:1708 CHERRY ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180
Practice Address - Country:US
Practice Address - Phone:601-638-3632
Practice Address - Fax:601-638-3998
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VANGUARD HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS176314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00220334Medicaid
MS00220334Medicaid