Provider Demographics
NPI:1851623664
Name:CENTRAL MS SCHOOL BASED HEALTH LLC.
Entity Type:Organization
Organization Name:CENTRAL MS SCHOOL BASED HEALTH LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:JOHNSON
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:662-674-0198
Mailing Address - Street 1:PO BOX 356
Mailing Address - Street 2:
Mailing Address - City:ETHEL
Mailing Address - State:MS
Mailing Address - Zip Code:39067-0356
Mailing Address - Country:US
Mailing Address - Phone:662-674-0198
Mailing Address - Fax:662-674-0098
Practice Address - Street 1:2268 COLLEGE STREET
Practice Address - Street 2:
Practice Address - City:ETHEL
Practice Address - State:MS
Practice Address - Zip Code:39067
Practice Address - Country:US
Practice Address - Phone:662-674-0198
Practice Address - Fax:662-674-0098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR853619363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00255854Medicaid
MS00255854Medicaid