NPIMap

Organization Active NPI

Pecan Grove

  • Nursing Facility/Intermediate Care Facility
  • Ellisville, MS
National Provider Identifier
1205904604
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nursing Facility/Intermediate Care FacilityTaxonomy code 313M00000X
License
284 Issued in MS
Legal business name
PECAN GROVE
Practice address
1101 Highway 11 S
Ellisville, MS 39437-4443
Phone
(601) 477-9384
Fax
(601) 477-5700
NPI assigned
Dec 1, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

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

Authorized official

Name
Suzie Lassiter
Title
Director of Facility
Phone
(601) 477-9384

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Nursing Facility/Intermediate Care Facility 313M00000X 284 MS Primary

Addresses

Primary practice location

1101 Highway 11 S
Ellisville, MS 39437-4443

Mailing address

1101 Highway 11 S
Ellisville, MS 39437-4443
Phone (601) 477-9384

Other identifiers 1

IdentifierTypeStateIssuer
00021847MedicaidMS

National Provider Directory

National Provider Directory
Tax ID family
Ellisville State School9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

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

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1164931200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1205904604",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1101 HIGHWAY 11 S",
            "city": "ELLISVILLE",
            "state": "MS",
            "postal_code": "394374443",
            "telephone_number": "601-477-9384",
            "fax_number": "601-477-5700"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1101 HIGHWAY 11 S",
            "city": "ELLISVILLE",
            "state": "MS",
            "postal_code": "394374443",
            "telephone_number": "601-477-9384",
            "fax_number": "601-477-5700"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PECAN GROVE",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-01",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "LASSITER",
        "authorized_official_first_name": "SUZIE",
        "authorized_official_title_or_position": "DIRECTOR OF FACILITY",
        "authorized_official_telephone_number": "601-477-9384"
    },
    "taxonomies": [
        {
            "code": "313M00000X",
            "taxonomy_group": "",
            "desc": "Nursing Facility/Intermediate Care Facility",
            "state": "MS",
            "license": "284",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00021847",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Ellisville, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.