Provider Demographics
NPI:1134360753
Name:CLINTON HEALTHCARE LLC
Entity type:Organization
Organization Name:CLINTON HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-304-0980
Mailing Address - Street 1:1251 PINEHAVEN RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-3455
Mailing Address - Country:US
Mailing Address - Phone:601-924-2996
Mailing Address - Fax:601-924-6447
Practice Address - Street 1:1251 PINEHAVEN RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-3455
Practice Address - Country:US
Practice Address - Phone:601-924-2996
Practice Address - Fax:601-924-6447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-11
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230093Medicaid
MS00230093Medicaid