1053423509 NPI number — MISSISSIPPI HOMECARE OF JACKSON, LLC

Table of content: (NPI 1053423509)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053423509 NPI number — MISSISSIPPI HOMECARE OF JACKSON, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSISSIPPI HOMECARE OF JACKSON, LLC
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:
1053423509
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 51266
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70505-1266
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-233-1307
Provider Business Mailing Address Fax Number:
337-233-5764

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
817 EAST RIVER PLACE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-352-5063
Provider Business Practice Location Address Fax Number:
601-352-7098
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NOVEMBER
Authorized Official First Name:
PETER
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
EXECUTIVE VICE PRESIDENT
Authorized Official Telephone Number:
337-233-1307

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  1294 , 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: 70265 . This is a "BLUE CROSS BLUE SHIELD OF" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 00770125 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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