Provider Demographics
NPI:1508951120
Name:NORTHEAST MISSISSIPPI PLANNING AND DEVELOPMENT DISTRICT
Entity Type:Organization
Organization Name:NORTHEAST MISSISSIPPI PLANNING AND DEVELOPMENT DISTRICT
Other - Org Name:ELDERLY AND DISABLED MEDICAID WAIVER PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-728-7038
Mailing Address - Street 1:P.O.BOX 600
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829
Mailing Address - Country:US
Mailing Address - Phone:662-728-7038
Mailing Address - Fax:662-728-2417
Practice Address - Street 1:619 E. PARKER
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829
Practice Address - Country:US
Practice Address - Phone:662-728-7038
Practice Address - Fax:662-728-2417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770312OtherPROVIDER NUMBER