Provider Demographics
NPI:1629392774
Name:SOUTH MISSISSIPPI REGIONAL CENTER
Entity Type:Organization
Organization Name:SOUTH MISSISSIPPI REGIONAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BENEFIT SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-867-1348
Mailing Address - Street 1:1170 W RAILROAD ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-4106
Mailing Address - Country:US
Mailing Address - Phone:228-867-1348
Mailing Address - Fax:228-214-5563
Practice Address - Street 1:1170 W RAILROAD ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560-4106
Practice Address - Country:US
Practice Address - Phone:228-867-1348
Practice Address - Fax:228-214-5563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS311261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09555710OtherPROVIDER NUMBER