Provider Demographics
NPI:1497736813
Name:DESOTO HEALTHCARE INC
Entity Type:Organization
Organization Name:DESOTO HEALTHCARE INC
Other - Org Name:DESOTO HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:TICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-928-5890
Mailing Address - Street 1:748 HALL ST
Mailing Address - Street 2:
Mailing Address - City:WIGGINS
Mailing Address - State:MS
Mailing Address - Zip Code:39577-2108
Mailing Address - Country:US
Mailing Address - Phone:601-928-5890
Mailing Address - Fax:601-928-5807
Practice Address - Street 1:7805 SOUTHCREST PKWY
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-4741
Practice Address - Country:US
Practice Address - Phone:662-349-7500
Practice Address - Fax:662-349-2069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS771314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0230185Medicaid
MS0230185Medicaid