Provider Demographics
NPI:1932856531
Name:340 DESOTO AVENUE EXT OPERATIONS, LLC
Entity type:Organization
Organization Name:340 DESOTO AVENUE EXT OPERATIONS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGHER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:LEHNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-698-9040
Mailing Address - Street 1:340 DESOTO AVENUE EXT
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-2814
Mailing Address - Country:US
Mailing Address - Phone:253-278-2258
Mailing Address - Fax:662-627-5654
Practice Address - Street 1:340 DESOTO AVENUE EXT
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-2814
Practice Address - Country:US
Practice Address - Phone:253-278-2258
Practice Address - Fax:662-627-5654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-04
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000230119Medicaid