Provider Demographics
NPI:1720036916
Name:COPIAH COMMUNITY CARE CENTER LLC
Entity Type:Organization
Organization Name:COPIAH COMMUNITY CARE CENTER LLC
Other - Org Name:COPIAH LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:TONI
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-709-1408
Mailing Address - Street 1:806 W GEORGETOWN ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39059-9453
Mailing Address - Country:US
Mailing Address - Phone:601-892-1881
Mailing Address - Fax:601-892-1985
Practice Address - Street 1:806 W GEORGETOWN ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39059-9453
Practice Address - Country:US
Practice Address - Phone:601-892-1881
Practice Address - Fax:601-892-1985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS949314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230165Medicaid
MS80413OtherBLUE CROSS BLUE SHIELD
MS00230165Medicaid