Provider Demographics
NPI:1891743274
Name:HUMPHREYS COMMUNITY CARE CENTER LLC
Entity Type:Organization
Organization Name:HUMPHREYS COMMUNITY CARE CENTER LLC
Other - Org Name:HUMPHREYS COUNTY NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:BELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-709-1408
Mailing Address - Street 1:500 CCC ROAD
Mailing Address - Street 2:
Mailing Address - City:BELZONI
Mailing Address - State:MS
Mailing Address - Zip Code:39038-3806
Mailing Address - Country:US
Mailing Address - Phone:662-247-1821
Mailing Address - Fax:662-247-2078
Practice Address - Street 1:500 CCC ROAD
Practice Address - Street 2:
Practice Address - City:BELZONI
Practice Address - State:MS
Practice Address - Zip Code:39038-3806
Practice Address - Country:US
Practice Address - Phone:662-247-1821
Practice Address - Fax:662-247-2078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS405314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230170Medicaid
MS000080383OtherBLUE CROSS BLUE SHIELD MS
MS255259Medicare Oscar/Certification