1154418481 NPI number — JEANS NON MEDICAL CARE RESPITE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154418481 NPI number — JEANS NON MEDICAL CARE RESPITE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEANS NON MEDICAL CARE RESPITE
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:
1154418481
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/13/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
430 WILLIAMS AVE
Provider Second Line Business Mailing Address:
P. O. BOX 72
Provider Business Mailing Address City Name:
SLEDGE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38670
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-382-8883
Provider Business Mailing Address Fax Number:
662-382-7776

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
612 BROAD STREET
Provider Second Line Business Practice Location Address:
612
Provider Business Practice Location Address City Name:
SLEDGE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38270
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-382-8883
Provider Business Practice Location Address Fax Number:
662-382-7776
Provider Enumeration Date:
10/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PHIPPS
Authorized Official First Name:
OZIE
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
662-382-8883

Provider Taxonomy Codes

  • Taxonomy code: 385H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 07354332 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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