Provider Demographics
NPI:1821335894
Name:SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC.
Entity Type:Organization
Organization Name:SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC.
Other - Org Name:PETAL UPPER ELEMENTARY SCHOOL
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAYE
Authorized Official - Middle Name:
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-545-8700
Mailing Address - Street 1:PO BOX 1729
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-1729
Mailing Address - Country:US
Mailing Address - Phone:601-545-3700
Mailing Address - Fax:601-450-2493
Practice Address - Street 1:400 HILLCREST LOOP
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-2634
Practice Address - Country:US
Practice Address - Phone:601-545-8700
Practice Address - Fax:601-450-2493
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-11
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS251016OtherMS MEDICARE PTAN
MS06404731Medicaid