Provider Demographics
NPI:1316360449
Name:MIDDLE MS ACCESS CORPORATION
Entity Type:Organization
Organization Name:MIDDLE MS ACCESS CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:601-940-0183
Mailing Address - Street 1:PO BOX 757
Mailing Address - Street 2:
Mailing Address - City:TERRY
Mailing Address - State:MS
Mailing Address - Zip Code:39170-0757
Mailing Address - Country:US
Mailing Address - Phone:601-940-0183
Mailing Address - Fax:
Practice Address - Street 1:620 W AMITE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39203-2618
Practice Address - Country:US
Practice Address - Phone:601-940-0183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-24
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS320800000320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness