1518040500 NPI number — REGION IV MH MR COMMISSION PHCY

Table of content: (NPI 1518040500)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518040500 NPI number — REGION IV MH MR COMMISSION PHCY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REGION IV MH MR COMMISSION PHCY
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:
1518040500
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 716
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOONEVILLE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38829-0716
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301B E CHAMBERS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOONEVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-728-3174
Provider Business Practice Location Address Fax Number:
662-728-3159
Provider Enumeration Date:
10/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SPEARMAN
Authorized Official First Name:
CHARLIE
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
662-286-9883

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 06596/1.1 , 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: 2047211 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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