Provider Demographics
NPI:1215745252
Name:555 JOHN R JUNKIN DRIVE OPCO LLC
Entity type:Organization
Organization Name:555 JOHN R JUNKIN DRIVE OPCO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOBACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-698-9040
Mailing Address - Street 1:555 JOHN R JUNKIN DR
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-4709
Mailing Address - Country:US
Mailing Address - Phone:601-442-4396
Mailing Address - Fax:601-442-0321
Practice Address - Street 1:555 JOHN R JUNKIN DR
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-4709
Practice Address - Country:US
Practice Address - Phone:601-442-4396
Practice Address - Fax:601-442-0321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-23
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000220160Medicaid