1821107996 NPI number — DESTINY HOSPICE PALLIATIVE CARE SPECIALTY SERCICES INC

Table of content: (NPI 1821107996)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821107996 NPI number — DESTINY HOSPICE PALLIATIVE CARE SPECIALTY SERCICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESTINY HOSPICE PALLIATIVE CARE SPECIALTY SERCICES 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:
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:
1821107996
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 190
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUTWILER
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38963-0190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-345-0077
Provider Business Mailing Address Fax Number:
662-345-2009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 SECOND ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUTWILER
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38963
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-345-0077
Provider Business Practice Location Address Fax Number:
662-345-2009
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RICHARD
Authorized Official First Name:
ALPHA
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
CEO/OWNER
Authorized Official Telephone Number:
662-345-0077

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  066 , 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: 00770571 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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