Provider Demographics
NPI:1548413628
Name:NORTHEAST MENTAL HEALTH-MENTAL RETARDATION COMMISSION
Entity Type:Organization
Organization Name:NORTHEAST MENTAL HEALTH-MENTAL RETARDATION COMMISSION
Other - Org Name:LIFECORE HEALTH GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:STALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-844-1717
Mailing Address - Street 1:2434 S EASON BLVD
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-6942
Mailing Address - Country:US
Mailing Address - Phone:662-844-1717
Mailing Address - Fax:662-680-6416
Practice Address - Street 1:2434 S EASON BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-6942
Practice Address - Country:US
Practice Address - Phone:662-844-1717
Practice Address - Fax:662-680-6416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-03
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04329807Medicaid
MS07453596Medicaid
253850Medicare Oscar/Certification
MS04329807Medicaid