1770938979 NPI number — TISHOMINGO HEALTH SERVICES, INC.

Table of content: (NPI 1770938979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770938979 NPI number — TISHOMINGO HEALTH SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TISHOMINGO HEALTH SERVICES, INC.
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:
6
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:
1770938979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
456 E PRESIDENT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUPELO
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38801-5515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-377-4685
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
296 HIGHWAY 72
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURNSVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38833-9104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-427-2073
Provider Business Practice Location Address Fax Number:
662-427-2074
Provider Enumeration Date:
04/26/2016

Additional Information

Authorized Official

Authorized Official Last Name:
TOPPIN
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CHIEF LEGAL OFFICER
Authorized Official Telephone Number:
662-377-4229

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  13-221 , 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)





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