1982610572 NPI number — REGION 12 COMMISSION ON MENTAL HEALTH & RETARDATION PINE BELT MEN

Table of content: (NPI 1982610572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982610572 NPI number — REGION 12 COMMISSION ON MENTAL HEALTH & RETARDATION PINE BELT MEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REGION 12 COMMISSION ON MENTAL HEALTH & RETARDATION PINE BELT MEN
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:
PINE BELT MENTAL HEALTH CARE RESOURCES
Provider Other Organization Name Type Code:
3
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:
1982610572
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 18679
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HATTIESBURG
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39404-8679
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-705-1906
Provider Business Mailing Address Fax Number:
601-705-1952

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 S 19TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HATTIESBURG
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39401-6171
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-544-4641
Provider Business Practice Location Address Fax Number:
601-584-4053
Provider Enumeration Date:
08/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MAYS
Authorized Official First Name:
JANET
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
601-705-1902

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  R12-1 , 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: 00018212 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: R121 . This is a "DMH CERTIFICATION" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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