Provider Demographics
NPI:1619012465
Name:DYNAMIC YAZOO CITY OPERATING COMPANY LLC
Entity Type:Organization
Organization Name:DYNAMIC YAZOO CITY OPERATING COMPANY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR ASST.
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-746-6651
Mailing Address - Street 1:925 CALHOUN AVE
Mailing Address - Street 2:
Mailing Address - City:YAZOO CITY
Mailing Address - State:MS
Mailing Address - Zip Code:39194-3229
Mailing Address - Country:US
Mailing Address - Phone:662-746-6651
Mailing Address - Fax:662-746-6090
Practice Address - Street 1:925 CALHOUN AVE
Practice Address - Street 2:
Practice Address - City:YAZOO CITY
Practice Address - State:MS
Practice Address - Zip Code:39194-3229
Practice Address - Country:US
Practice Address - Phone:662-746-6651
Practice Address - Fax:662-746-6090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230074Medicaid
MS255146Medicare ID - Type Unspecified