Provider Demographics
NPI:1629600945
Name:MODERN HOPE OF MS,LLC
Entity Type:Organization
Organization Name:MODERN HOPE OF MS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-745-1499
Mailing Address - Street 1:755 HIGHLAND OAKS DR STE 204
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-7106
Mailing Address - Country:US
Mailing Address - Phone:336-745-1499
Mailing Address - Fax:434-549-5788
Practice Address - Street 1:16 NORTHTOWN DR STE 106
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-3058
Practice Address - Country:US
Practice Address - Phone:336-745-1499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-05
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty