Provider Demographics
NPI:1518159862
Name:BELHAVEN SENIOR CARE
Entity type:Organization
Organization Name:BELHAVEN SENIOR CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:CORLEY
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:601-898-6080
Mailing Address - Street 1:111 KELLY BLVD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110
Mailing Address - Country:US
Mailing Address - Phone:601-898-6080
Mailing Address - Fax:601-898-6348
Practice Address - Street 1:111 KELLY BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110
Practice Address - Country:US
Practice Address - Phone:601-898-6080
Practice Address - Fax:601-898-6348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS624314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230161Medicaid