Provider Demographics
NPI:1720181191
Name:ELLISVILLE STATE SCHOOL
Entity Type:Organization
Organization Name:ELLISVILLE STATE SCHOOL
Other - Org Name:CLOVER CIRCLE ICF/MR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACCOUNTING AUDITOR 1
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAM
Authorized Official - Middle Name:K
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-477-5606
Mailing Address - Street 1:1101 HIGHWAY 11 S
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39437-4443
Mailing Address - Country:US
Mailing Address - Phone:601-477-9384
Mailing Address - Fax:601-477-5700
Practice Address - Street 1:1101 HIGHWAY 11 S
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437-4443
Practice Address - Country:US
Practice Address - Phone:601-477-9384
Practice Address - Fax:601-477-5700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS233302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00021831Medicaid