Organization
2ND GENERATION HEALTHCARE, LLC
Active
Other names
The Grove Outpatient Therapy Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL BRADSHAW (ADMINISTRATOR)
(601) 736-4747
Entity
Organization
Contact information
Practice address
11 PECAN DRIVE, COLUMBIA, MS 39429
(601) 736-4747
Mailing address
11 PECAN DRIVE, COLUMBIA, MS 39429
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
461
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
08039271
—
MS
01
—
255316
MEDICARE PROVIDER NUMBER
MS
Enumeration date
10/19/2010
Last updated
06/01/2018
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