Provider Demographics
NPI:1740668755
Name:BROADWAY MANOR LIMITED LIABILITY
Entity type:Organization
Organization Name:BROADWAY MANOR LIMITED LIABILITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JMELBA
Authorized Official - Middle Name:H
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-702-5007
Mailing Address - Street 1:515 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-2552
Mailing Address - Country:US
Mailing Address - Phone:662-702-5007
Mailing Address - Fax:
Practice Address - Street 1:446 N BROADWAY STREET
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-2552
Practice Address - Country:US
Practice Address - Phone:662-702-5007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-11
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1096310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility