Provider Demographics
NPI:1891965612
Name:MISSISSIPPI BAND OF CHOCTAW INDIANS
Entity Type:Organization
Organization Name:MISSISSIPPI BAND OF CHOCTAW INDIANS
Other - Org Name:CHOCTAW RESIDENTIAL CENTER PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TRIBAL CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-656-5251
Mailing Address - Street 1:210 HOSPITAL CIR
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:MS
Mailing Address - Zip Code:39350-6781
Mailing Address - Country:US
Mailing Address - Phone:601-656-2211
Mailing Address - Fax:601-663-7721
Practice Address - Street 1:135 HOSPITAL CIR
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:MS
Practice Address - Zip Code:39350-6780
Practice Address - Country:US
Practice Address - Phone:601-656-2582
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSISSIPPI BAND OF CHOCTAW INDIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-07
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS583313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015768Medicaid
TXTEZ041Medicare PIN