Provider Demographics
NPI:1225167430
Name:PRENTISS REGIONAL HOSPITAL AND ECF, INC.
Entity Type:Organization
Organization Name:PRENTISS REGIONAL HOSPITAL AND ECF, INC.
Other - Org Name:JEFFERSON DAVIS COMMUNITY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MCCALL
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:601-792-4276
Mailing Address - Street 1:PO BOX 1288
Mailing Address - Street 2:
Mailing Address - City:PRENTISS
Mailing Address - State:MS
Mailing Address - Zip Code:39474-1288
Mailing Address - Country:US
Mailing Address - Phone:601-792-4276
Mailing Address - Fax:601-792-2947
Practice Address - Street 1:1320 WINFIELD ST.
Practice Address - Street 2:
Practice Address - City:PRENTISS
Practice Address - State:MS
Practice Address - Zip Code:39474
Practice Address - Country:US
Practice Address - Phone:601-792-4276
Practice Address - Fax:601-792-2947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS254314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230059Medicaid
MS255050Medicare Oscar/Certification