Provider Demographics
NPI:1003243965
Name:REGION IV
Entity Type:Organization
Organization Name:REGION IV
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LARA
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:662-563-9176
Mailing Address - Street 1:120 RANDY HENDRIX DR
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38606-7664
Mailing Address - Country:US
Mailing Address - Phone:662-563-9176
Mailing Address - Fax:662-563-0269
Practice Address - Street 1:120 RANDY HENDRIX DR
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:MS
Practice Address - Zip Code:38606-7664
Practice Address - Country:US
Practice Address - Phone:662-563-9176
Practice Address - Fax:662-563-0269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-08
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1699869537Medicaid