Provider Demographics
NPI:1003986993
Name:WEST BOLIVAR ELEMENTARY
Entity Type:Organization
Organization Name:WEST BOLIVAR ELEMENTARY
Other - Org Name:WEST BOLIVAR WELL CHILD CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-759-3525
Mailing Address - Street 1:1212 SOUTH MAIN STREET
Mailing Address - Street 2:P.O. BOX 429
Mailing Address - City:ROSEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38769-0429
Mailing Address - Country:US
Mailing Address - Phone:662-759-3823
Mailing Address - Fax:662-759-0027
Practice Address - Street 1:1212 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:MS
Practice Address - Zip Code:38769-0429
Practice Address - Country:US
Practice Address - Phone:662-759-3823
Practice Address - Fax:662-759-0027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR865655251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare