Provider Demographics
NPI:1467495127
Name:PRENTISS REGIONAL HOSPITAL AND EXTENDED CARE FACILITY, INC.
Entity Type:Organization
Organization Name:PRENTISS REGIONAL HOSPITAL AND EXTENDED CARE FACILITY, INC.
Other - Org Name:JEFFERSON DAVIS COMMUNITY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CURTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-792-1232
Mailing Address - Street 1:1102 ROSE STREET
Mailing Address - Street 2:P.O. BOX 1288
Mailing Address - City:PRENTISS
Mailing Address - State:MS
Mailing Address - Zip Code:39474-1288
Mailing Address - Country:US
Mailing Address - Phone:601-792-4276
Mailing Address - Fax:601-792-2947
Practice Address - Street 1:1102 ROSE STREET
Practice Address - Street 2:
Practice Address - City:PRENTISS
Practice Address - State:MS
Practice Address - Zip Code:39474-1288
Practice Address - Country:US
Practice Address - Phone:601-792-4276
Practice Address - Fax:601-792-2947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16-179282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00220441Medicaid
MS00220441Medicaid