1285280180 NPI number — DELTA HEALTH CENTER, INC

Table of content: (NPI 1285280180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285280180 NPI number — DELTA HEALTH CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DELTA HEALTH CENTER, 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:
1285280180
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
702 MARTIN LUTHER KING ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUND BAYOU
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38762-9314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-741-8800
Provider Business Mailing Address Fax Number:
662-741-2700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
506 WASHINGTON AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOORHEAD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-246-5680
Provider Business Practice Location Address Fax Number:
662-246-5080
Provider Enumeration Date:
08/15/2019

Additional Information

Authorized Official

Authorized Official Last Name:
SMALL
Authorized Official First Name:
MYRTIS
Authorized Official Middle Name:
Authorized Official Title or Position:
HR-CREDENTIALING DIRECTOR
Authorized Official Telephone Number:
662-741-8889

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01635257 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09013118 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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