Provider Demographics
NPI:1659555761
Name:TALLAHATCHIE GENERAL HOSPITAL AND EXTENDED CARE FACILITY
Entity Type:Organization
Organization Name:TALLAHATCHIE GENERAL HOSPITAL AND EXTENDED CARE FACILITY
Other - Org Name:EXTENDED CARE FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:VEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-625-7111
Mailing Address - Street 1:PO BOX 230
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:MS
Mailing Address - Zip Code:38921
Mailing Address - Country:US
Mailing Address - Phone:662-647-5535
Mailing Address - Fax:662-647-8432
Practice Address - Street 1:141 DR T. T. LEWIS CIRCLE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:MS
Practice Address - Zip Code:38921
Practice Address - Country:US
Practice Address - Phone:662-647-5535
Practice Address - Fax:662-647-8432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1054313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00023141Medicaid