Mississippi Band of Choctaw Indians
Organization Active NPI Nursing Facility/Intermediate Care Facility · Choctaw, MS
NPI 1154379469 · NPPES record last updated Nov 6, 2013
Key facts
- NPI
- 1154379469
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Nursing Facility/Intermediate Care Facility 313M00000X
- License
- 583 (MS)
- Legal business name
- MISSISSIPPI BAND OF CHOCTAW INDIANS
- Practice address
- 135 Hospital Cir
Choctaw, MS 39350-6780 - Phone
- (601) 656-2582
- NPI assigned
- May 5, 2006
- Organization subpart
- No
Authorized official
- Name
- Ms. Wendy Michelle Moran
- Title
- Nursing Home Administrator
- Phone
- (601) 656-2582
Owners & managing parties with NPI records 2
Other NPIs with the same Medicare PAC ID 2
Corporate family (same tax ID) 9
Practitioners 25
-
Michelle S Atkinson, DNP
-
Brandie D Buckley, FNP
-
Gwendolyn Denise Burnside, FNP-C
-
Johnny Lee Cosby, OD
-
Teresa K. Cumberland, FNP
-
Gregory Andrew Gordon, M.D.
-
Shannon Victoria Johnson, WHNP
-
Min S Kim, MD
-
Heather Patchin, WHNP
-
Leah Denise Phillips, FNP
-
Kelly Seid, M.D.
-
Donna Demetral Snow, CNP
-
Tiah Rae York, FNP-C
-
Nestor L. Olivo-Crespo, M.D.
-
Nathan Richard Randall, D.P.M.
-
Manuel Lim Ong Jr., M.D.
Affiliated clinicians 2
-
Manuel Lim Ong Jr., M.D.
Medicare Care Compare: Nursing home
- Listed as
- Choctaw Residential Center
- 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
- Certified beds
- 120 · 112.2 residents per day on average
- Penalties (3 years)
- 1 · fines totaling $13,757
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 25D0670016 | Choctaw Residential Center | Certificate of waiver | Aug 31, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MS
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
- Government · Proprietary
- Enrollment address
- 135 Residential Center Rd
Choctaw, MS 39350-6780 - Nursing home name
- CHOCTAW RESIDENTIAL CENTER
All disclosed owners & managing parties 4
| Name | Role | Since | Share |
|---|---|---|---|
| Mississippi Band of Choctaw Indians |
5% Or Greater Direct Ownership Interest | Oct 22, 1987 | 100% |
| Shelley Hale |
W-2 Managing Employee |
Feb 3, 2014 | 100% |
| Berta Gay Flake |
W-2 Managing Employee |
Oct 16, 2019 | 100% |
| Cyrus Ben |
Corporate Officer |
Jul 9, 2019 | 100% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20130506000019 | MS | Part a Provider - Skilled Nursing Facility | 4385546662 | Practice locations: Choctaw, MS |
National Provider Directory
- Tax ID family
- Choctaw Health Center Pharmacy
Locations
135 Residential Center Rd
Choctaw, MS 39350
Phone (601) 389-2812
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Nursing Facility/Intermediate Care Facility | 313M00000X | 583 | MS | Yes |
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 identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 25-5339 | Other | MS | MEDICARE CCN |
| 00023031 | Medicaid | MS |
Other names
- Choctaw Residential Center Enterprise
Other providers in Choctaw, MS
- Vivian J McGarrity
- Nancy Melton
- Karen Louise Miller
- Mississippi Band of Choctaw Indians
- Mississippi Band of Choctaw Indians
- Mississippi Band of Choctaw Indians
- Mississippi Band of Choctaw Indians
- Mississippi Band of Choctaw Indians
- Mississippi Band of Choctaw Indians
- Mississippi Band of Choctaw Indians
All providers in Choctaw, MS · Nursing Facility/Intermediate Care Facility in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 6, 2013. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.