Provider Demographics
NPI:1750456034
Name:LEAKE EXTENDED CARE FACILITY
Entity Type:Organization
Organization Name:LEAKE EXTENDED CARE FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOOLSBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-267-1100
Mailing Address - Street 1:310 ELLIS ST
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MS
Mailing Address - Zip Code:39051-3809
Mailing Address - Country:US
Mailing Address - Phone:601-267-1100
Mailing Address - Fax:601-267-1211
Practice Address - Street 1:310 ELLIS ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MS
Practice Address - Zip Code:39051-3809
Practice Address - Country:US
Practice Address - Phone:601-267-1100
Practice Address - Fax:601-267-1211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS214313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230186Medicaid