Provider Demographics
NPI:1659693083
Name:AMITE COUNTY MEDICAL SERVICES, INC.
Entity Type:Organization
Organization Name:AMITE COUNTY MEDICAL SERVICES, INC.
Other - Org Name:LIBERTY DENTAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:POOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-657-4326
Mailing Address - Street 1:PO BOX 511
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MS
Mailing Address - Zip Code:39645-0511
Mailing Address - Country:US
Mailing Address - Phone:601-657-1236
Mailing Address - Fax:601-657-9181
Practice Address - Street 1:102 WEST FREEDOM DRIVE
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MS
Practice Address - Zip Code:39645
Practice Address - Country:US
Practice Address - Phone:601-657-1236
Practice Address - Fax:601-657-9181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-26
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015383Medicaid