Provider Demographics
NPI:1013191337
Name:MOUND BAYOU PUBLIC SCHOOL DISTRICT
Entity Type:Organization
Organization Name:MOUND BAYOU PUBLIC SCHOOL DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:EDS ADMINISTRATION
Authorized Official - Phone:662-741-2555
Mailing Address - Street 1:301 MARTIN LUTHER KING ST
Mailing Address - Street 2:
Mailing Address - City:MOUND BAYOU
Mailing Address - State:MS
Mailing Address - Zip Code:38762-9738
Mailing Address - Country:US
Mailing Address - Phone:662-741-2555
Mailing Address - Fax:662-741-2726
Practice Address - Street 1:202 W MARTIN LUTHER KING ST
Practice Address - Street 2:
Practice Address - City:MOUND BAYOU
Practice Address - State:MS
Practice Address - Zip Code:38762-9775
Practice Address - Country:US
Practice Address - Phone:662-741-2433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09015483261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015483Medicaid