Provider Demographics
NPI:1033143284
Name:SOUTH MISSISSIPPI REGIONAL CENTER
Entity Type:Organization
Organization Name:SOUTH MISSISSIPPI REGIONAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FACILITY
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:228-867-1300
Mailing Address - Street 1:1170 W RAILROAD ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-4106
Mailing Address - Country:US
Mailing Address - Phone:228-867-1300
Mailing Address - Fax:228-214-5563
Practice Address - Street 1:1170 W RAILROAD ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560-4106
Practice Address - Country:US
Practice Address - Phone:228-867-1300
Practice Address - Fax:228-214-5563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS311315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00021842Medicaid
MS09555710Medicaid
MS00770072Medicaid
MS00095206Medicaid
MS09015481Medicaid