NPIMap

Organization Active NPI

Mississippi Band of Choctaw Indians

Doing business as Choctaw Residential Center Enterprise

  • Nursing Facility/Intermediate Care Facility
  • Choctaw, MS
National Provider Identifier
1154379469
Registry record updated Nov 6, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nursing Facility/Intermediate Care FacilityTaxonomy code 313M00000X
License
583 Issued in MS
Legal business name
MISSISSIPPI BAND OF CHOCTAW INDIANS
Doing business as
Choctaw Residential Center Enterprise
Practice address
135 Hospital Cir
Choctaw, MS 39350-6780
Phone
(601) 656-2582
NPI assigned
May 5, 2006
Last updated
Nov 6, 2013By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 6, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Wendy Michelle Moran
Title
Nursing Home Administrator
Phone
(601) 656-2582

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Nursing Facility/Intermediate Care Facility 313M00000X 583 MS Primary

Addresses

Primary practice location

135 Hospital Cir
Choctaw, MS 39350-6780

Mailing address

135 Hospital Cir
Choctaw, MS 39350-6780
Phone (601) 656-2582

Other names 1

  • Choctaw Residential Center Enterprise Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20130506000019 MS Part A Provider - Skilled Nursing Facility 4385546662 Practice locations: Choctaw, MS

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1154379469. Details of each certification follow.

Skilled nursing facility certification: CCN 255339

Legal name
MISSISSIPPI BAND OF CHOCTAW INDIANS
Doing business as
CHOCTAW RESIDENTIAL CENTER
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Aug 25, 2013
Last certification
Mar 6, 2025
Beds
120
Ownership / control type
Other Nonprofit
Organization structure
GovernmentProprietary
Enrollment address
135 Residential Center Rd
Choctaw, MS 39350-6780
Nursing home name
CHOCTAW RESIDENTIAL CENTER

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Care Compare: Nursing home

Medicare Care Compare
Listed as
Choctaw Residential CenterCCN 255339 · All quality measures
Overall star rating
2 of 5
Health inspections
2 of 5
Staffing
4 of 5
Quality measures
2 of 5
Type
Medicare and Medicaid
Ownership
Non profit - Other
Certified
Aug 25, 2013
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
120112.2 residents per day on average
Penalties (3 years)
1Fines totaling $13,757

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
25D0670016Choctaw Residential Center135 Residential Center Rd, Philadelphia, MS 39350Certificate of waiverAug 31, 2026

National Provider Directory

National Provider Directory
Tax ID family
Choctaw Health Center Pharmacy10 organizations share this tax ID, including this one

Other organizations with this tax ID 9

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 4

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Mississippi Band of Choctaw Indians Organization, Choctaw, MS 5% Or Greater Direct Ownership Interest Oct 22, 1987 100%
Shelley Hale Individual W-2 Managing EmployeeAdministrator Feb 3, 2014 100%
Berta Gay Flake Individual W-2 Managing EmployeeAdministrator Oct 16, 2019 100%
Cyrus Ben Individual Corporate OfficerBoard Chairperson Jul 9, 2019 100%

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 2

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1146787200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1383696000000",
    "number": "1154379469",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "135 HOSPITAL CIR",
            "city": "CHOCTAW",
            "state": "MS",
            "postal_code": "393506780",
            "telephone_number": "601-656-2582"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "135 HOSPITAL CIR",
            "city": "CHOCTAW",
            "state": "MS",
            "postal_code": "393506780",
            "telephone_number": "601-656-2582"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MISSISSIPPI BAND OF CHOCTAW INDIANS",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-05",
        "last_updated": "2013-11-06",
        "status": "A",
        "authorized_official_last_name": "MORAN",
        "authorized_official_first_name": "WENDY",
        "authorized_official_middle_name": "MICHELLE",
        "authorized_official_title_or_position": "NURSING HOME ADMINISTRATOR",
        "authorized_official_telephone_number": "601-656-2582",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "313M00000X",
            "taxonomy_group": "",
            "desc": "Nursing Facility/Intermediate Care Facility",
            "state": "MS",
            "license": "583",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Choctaw Residential Center Enterprise",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Choctaw, MS

Sources for this page

Verify at the official NPI Registry.