1184662694 NPI number — SW MS MENTAL HEALTH MENTAL RETARDATION COMMISSION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184662694 NPI number — SW MS MENTAL HEALTH MENTAL RETARDATION COMMISSION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SW MS MENTAL HEALTH MENTAL RETARDATION COMMISSION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184662694
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 768
Provider Second Line Business Mailing Address:
1701 WHITE ST
Provider Business Mailing Address City Name:
MCCOMB
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39649
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-684-2173
Provider Business Mailing Address Fax Number:
601-249-4234

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 WHITE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCCOMB
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-684-2173
Provider Business Practice Location Address Fax Number:
601-249-4234
Provider Enumeration Date:
06/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DORSEY
Authorized Official First Name:
MONTAVIA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MGR
Authorized Official Telephone Number:
601-249-4235

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00018211 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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