Provider Demographics
NPI:1336672641
Name:MID SOUTH HOME CARE, LLC
Entity Type:Organization
Organization Name:MID SOUTH HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-563-8092
Mailing Address - Street 1:49 RED AUTUMN LN NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-6025
Mailing Address - Country:US
Mailing Address - Phone:601-563-8092
Mailing Address - Fax:
Practice Address - Street 1:234 W COURT ST
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2750
Practice Address - Country:US
Practice Address - Phone:601-563-8092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1719253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care