Provider Demographics
NPI:1922096866
Name:HATTIESBURG CONVALESCENT HOME, INC.
Entity Type:Organization
Organization Name:HATTIESBURG CONVALESCENT HOME, INC.
Other - Org Name:HATTIESBURG CONVALESCENT CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEWELL
Authorized Official - Middle Name:C
Authorized Official - Last Name:MCMAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-544-4230
Mailing Address - Street 1:514 BAY ST
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-3933
Mailing Address - Country:US
Mailing Address - Phone:601-544-4230
Mailing Address - Fax:601-582-2480
Practice Address - Street 1:514 BAY ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-3933
Practice Address - Country:US
Practice Address - Phone:601-544-4230
Practice Address - Fax:601-582-2480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS25314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0023061Medicaid