Provider Demographics
NPI:1649592791
Name:INDEPENDENT HEALTHCARE MANAGEMENT, INC,
Entity Type:Organization
Organization Name:INDEPENDENT HEALTHCARE MANAGEMENT, INC,
Other - Org Name:S. E. LACKEY MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN OF THE BOARD
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-849-6440
Mailing Address - Street 1:330 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:MS
Mailing Address - Zip Code:39074-3508
Mailing Address - Country:US
Mailing Address - Phone:601-469-4151
Mailing Address - Fax:601-469-3681
Practice Address - Street 1:330 N BROAD ST
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:MS
Practice Address - Zip Code:39074-3508
Practice Address - Country:US
Practice Address - Phone:601-469-4151
Practice Address - Fax:601-469-3681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-17
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13-033282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09013565Medicaid