Provider Demographics
NPI:1275768319
Name:SOUTHWEST DEVELOPMENT CORPORATION, INC.
Entity Type:Organization
Organization Name:SOUTHWEST DEVELOPMENT CORPORATION, INC.
Other - Org Name:MEDGAR EVERS RESPITE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:T
Authorized Official - Last Name:IRVING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-786-3955
Mailing Address - Street 1:210 GILCHRIST STREET
Mailing Address - Street 2:POST OFFICE BOX 699
Mailing Address - City:FAYETTE
Mailing Address - State:MS
Mailing Address - Zip Code:39069-0699
Mailing Address - Country:US
Mailing Address - Phone:601-786-3955
Mailing Address - Fax:601-786-3910
Practice Address - Street 1:210 GILCHRIST STREET
Practice Address - Street 2:POST OFFICE BOX 699
Practice Address - City:FAYETTE
Practice Address - State:MS
Practice Address - Zip Code:39069-0699
Practice Address - Country:US
Practice Address - Phone:601-786-3955
Practice Address - Fax:601-786-3910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-19
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09056303385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0770119Medicaid
MS0770119Medicaid