Provider Demographics
NPI:1750471942
Name:ST. JUDE HOSPICE MISSISSIPPI, LLC
Entity Type:Organization
Organization Name:ST. JUDE HOSPICE MISSISSIPPI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:MORELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-221-9155
Mailing Address - Street 1:13375 UNIVERSITY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-8261
Mailing Address - Country:US
Mailing Address - Phone:515-221-9155
Mailing Address - Fax:515-221-9157
Practice Address - Street 1:3166 W JACKSON ST
Practice Address - Street 2:SUITE # 2
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-7154
Practice Address - Country:US
Practice Address - Phone:662-841-5907
Practice Address - Fax:662-841-5910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS094251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03504070Medicaid
MS251589Medicare Oscar/Certification
MS251589Medicare ID - Type UnspecifiedHOSPICE HOME CARE