1821145285 NPI number — STA-HOME HOSPICE

Table of content: (NPI 1821145285)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821145285 NPI number — STA-HOME HOSPICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STA-HOME HOSPICE
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:
1821145285
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
406 BRIARWOOD DR
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39206-3039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-991-1933
Provider Business Mailing Address Fax Number:
601-991-3343

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
406 BRIARWOOD DR
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39206-3039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-991-1933
Provider Business Practice Location Address Fax Number:
601-991-3343
Provider Enumeration Date:
01/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WOOD
Authorized Official First Name:
GLENN
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
DIRECTOR OF COMPLIANCE
Authorized Official Telephone Number:
601-956-5100

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  023 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00770002 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000070004 . This is a "BCBS OF MS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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