Provider Demographics
NPI:1467437210
Name:MISSISSIPPI STATE DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:MISSISSIPPI STATE DEPARTMENT OF HEALTH
Other - Org Name:NORTHEAST HOME HEALTH AGENCY 2B
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF HOME HEALTH
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:601-576-7853
Mailing Address - Street 1:517 CHURCH STREET
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829
Mailing Address - Country:US
Mailing Address - Phone:662-728-5391
Mailing Address - Fax:662-728-0132
Practice Address - Street 1:517 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829
Practice Address - Country:US
Practice Address - Phone:662-728-5391
Practice Address - Fax:662-728-0132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-14
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS9481251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00070500Medicaid
MS00070500Medicaid