Provider Demographics
NPI:1538719125
Name:MOCKINGBIRD ASSISTED LIVING, LLC
Entity type:Organization
Organization Name:MOCKINGBIRD ASSISTED LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:JOE
Authorized Official - Last Name:GROOMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-596-3030
Mailing Address - Street 1:1101 W CHAMBERS DR
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-6840
Mailing Address - Country:US
Mailing Address - Phone:662-416-5469
Mailing Address - Fax:662-596-3052
Practice Address - Street 1:1101 W CHAMBERS DR
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-6840
Practice Address - Country:US
Practice Address - Phone:662-416-5469
Practice Address - Fax:662-596-3052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility