Provider Demographics
NPI:1639471055
Name:PROVIDENCE PCC OF BATESVILLE
Entity Type:Organization
Organization Name:PROVIDENCE PCC OF BATESVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAT
Authorized Official - Middle Name:R
Authorized Official - Last Name:GUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-563-2345
Mailing Address - Street 1:PO BOX 1632
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38606-4132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:640 KEATING RD
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:MS
Practice Address - Zip Code:38606-8301
Practice Address - Country:US
Practice Address - Phone:662-563-2345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS879310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility