Provider Demographics
NPI:1457341976
Name:CLC OF IUKA, LLC
Entity Type:Organization
Organization Name:CLC OF IUKA, LLC
Other - Org Name:TISHOMINGO COMMUNITY LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:662-680-3148
Mailing Address - Street 1:PO BOX 562
Mailing Address - Street 2:
Mailing Address - City:IUKA
Mailing Address - State:MS
Mailing Address - Zip Code:38852-0562
Mailing Address - Country:US
Mailing Address - Phone:662-423-3422
Mailing Address - Fax:662-423-5259
Practice Address - Street 1:1410 W QUITMAN ST
Practice Address - Street 2:
Practice Address - City:IUKA
Practice Address - State:MS
Practice Address - Zip Code:38852-1129
Practice Address - Country:US
Practice Address - Phone:662-423-3422
Practice Address - Fax:662-423-5259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS643314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0230179Medicaid
MS0230179Medicaid