Provider Demographics
NPI:1922271360
Name:HERITAGE MANOR PCH, INC.
Entity Type:Organization
Organization Name:HERITAGE MANOR PCH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARROL
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HUDSPETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-757-0059
Mailing Address - Street 1:PO BOX 1337
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MS
Mailing Address - Zip Code:39654-1337
Mailing Address - Country:US
Mailing Address - Phone:601-886-7251
Mailing Address - Fax:601-886-9990
Practice Address - Street 1:2051 FERGUSON MILL RD
Practice Address - Street 2:
Practice Address - City:SILVER CREEK
Practice Address - State:MS
Practice Address - Zip Code:39663-4435
Practice Address - Country:US
Practice Address - Phone:601-886-7251
Practice Address - Fax:601-886-9990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS875310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06376862Medicaid