Provider Demographics
NPI:1235270588
Name:STA-HOME HEALTH AGENCY OF GREENWOOD, INC.
Entity Type:Organization
Organization Name:STA-HOME HEALTH AGENCY OF GREENWOOD, INC.
Other - Org Name:ACCENTCARE HOME HEALTH OF GREENWOOD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP LEGAL
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:SISCEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-221-0465
Mailing Address - Street 1:17855 DALLAS PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-6857
Mailing Address - Country:US
Mailing Address - Phone:972-201-3819
Mailing Address - Fax:
Practice Address - Street 1:205 WALTHALL ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-4428
Practice Address - Country:US
Practice Address - Phone:601-956-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11095251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770110Medicaid
MS00770110Medicaid