Provider Demographics
NPI:1609866235
Name:KEMPER COUNTY LTC INC
Entity Type:Organization
Organization Name:KEMPER COUNTY LTC INC
Other - Org Name:MISSISSIPPI CARE CENTER OF DEKALB LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:C
Authorized Official - Last Name:NESTER
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:601-743-5888
Mailing Address - Street 1:PO BOX 577
Mailing Address - Street 2:
Mailing Address - City:DE KALB
Mailing Address - State:MS
Mailing Address - Zip Code:39328-0577
Mailing Address - Country:US
Mailing Address - Phone:601-743-5888
Mailing Address - Fax:601-743-4506
Practice Address - Street 1:220 WILLOW AVE
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:MS
Practice Address - Zip Code:39328-0577
Practice Address - Country:US
Practice Address - Phone:601-743-5888
Practice Address - Fax:601-743-4506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS358314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0230087Medicaid
255251Medicare ID - Type Unspecified