Provider Demographics
NPI:1861645657
Name:REGION 12 COMMISSION ON MENTAL HEALTH & RETARDATION PINE
Entity Type:Organization
Organization Name:REGION 12 COMMISSION ON MENTAL HEALTH & RETARDATION PINE
Other - Org Name:PINE BELT MENTAL HEALTHCARE RESOURCES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-544-4641
Mailing Address - Street 1:103 S 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-6171
Mailing Address - Country:US
Mailing Address - Phone:601-544-4641
Mailing Address - Fax:601-450-4632
Practice Address - Street 1:103 S 19TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-6171
Practice Address - Country:US
Practice Address - Phone:601-544-4641
Practice Address - Fax:601-450-4632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-24
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS07864/5.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2117558OtherPK