Provider Demographics
NPI:1770602435
Name:DYNAMIC CLEVELAND OPERATING COMPANY LLC
Entity type:Organization
Organization Name:DYNAMIC CLEVELAND OPERATING COMPANY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-843-5347
Mailing Address - Street 1:200 N MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2821
Mailing Address - Country:US
Mailing Address - Phone:662-843-5347
Mailing Address - Fax:
Practice Address - Street 1:200 N MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2821
Practice Address - Country:US
Practice Address - Phone:662-843-5347
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230065Medicaid
MS00230065Medicaid