Provider Demographics
NPI:1376840058
Name:MISSISSIPPI ADOLESCENT CENTER
Entity Type:Organization
Organization Name:MISSISSIPPI ADOLESCENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR, MISSISSIPPI DEP
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:LEGRAND
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:601-359-1288
Mailing Address - Street 1:760 BROOKMAN DRIVE EXTENSION
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2340
Mailing Address - Country:US
Mailing Address - Phone:601-823-5700
Mailing Address - Fax:601-823-5769
Practice Address - Street 1:760 BROOKMAN DRIVE EXTENSION
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2340
Practice Address - Country:US
Practice Address - Phone:601-823-5700
Practice Address - Fax:601-823-5769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-16
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities