Provider Demographics
NPI:1245663251
Name:METHODIST HOME ROAD LIVING CENTER
Entity type:Organization
Organization Name:METHODIST HOME ROAD LIVING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PEBLES
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES-WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:769-257-7232
Mailing Address - Street 1:4560 METHODIST HOME ROAD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213
Mailing Address - Country:US
Mailing Address - Phone:769-257-7232
Mailing Address - Fax:769-257-7745
Practice Address - Street 1:4560 METHODIST HOME ROAD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213
Practice Address - Country:US
Practice Address - Phone:769-257-7232
Practice Address - Fax:769-257-7745
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:METHODIST HOME ROAD LIVING CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP321453164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS078890066OtherDUNS