Provider Demographics
NPI:1740228881
Name:VICKSBURG HEALTHCARE LLC
Entity Type:Organization
Organization Name:VICKSBURG HEALTHCARE LLC
Other - Org Name:MERIT HEALTH RIVER REGION WEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LALOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:629-215-3953
Mailing Address - Street 1:PO BOX 841672
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1672
Mailing Address - Country:US
Mailing Address - Phone:601-883-5000
Mailing Address - Fax:601-883-3090
Practice Address - Street 1:1111 N FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5102
Practice Address - Country:US
Practice Address - Phone:601-883-5000
Practice Address - Fax:601-883-3090
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VICKSBURG HEALTHCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-02
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1749079Medicaid
25S031Medicare Oscar/Certification