Provider Demographics
NPI:1144407420
Name:SOUTHWEST HEALTH AGENCY FOR RURAL PEOPLE, INC
Entity Type:Organization
Organization Name:SOUTHWEST HEALTH AGENCY FOR RURAL PEOPLE, INC
Other - Org Name:SHARP FAMITY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-876-4926
Mailing Address - Street 1:PO BOX 256
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MS
Mailing Address - Zip Code:39429-0256
Mailing Address - Country:US
Mailing Address - Phone:601-731-9108
Mailing Address - Fax:601-731-9190
Practice Address - Street 1:501 EAGLE DAY AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-3605
Practice Address - Country:US
Practice Address - Phone:601-731-9108
Practice Address - Fax:601-731-9190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015059Medicaid
MS231869OtherMEDICARE