Provider Demographics
NPI:1750306601
Name:DELCO INC DBA BROOKWOOD MANOR NURSING CENTER
Entity Type:Organization
Organization Name:DELCO INC DBA BROOKWOOD MANOR NURSING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-394-2331
Mailing Address - Street 1:1300 MELODY LANE
Mailing Address - Street 2:
Mailing Address - City:LEAKESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39451-0640
Mailing Address - Country:US
Mailing Address - Phone:601-394-2331
Mailing Address - Fax:601-394-2738
Practice Address - Street 1:1300 MELODY LANE
Practice Address - Street 2:
Practice Address - City:LEAKESVILLE
Practice Address - State:MS
Practice Address - Zip Code:39451-0640
Practice Address - Country:US
Practice Address - Phone:601-394-2331
Practice Address - Fax:601-394-2738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS620314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230133Medicaid
MS255179Medicare Oscar/Certification