Provider Demographics
NPI:1952047391
Name:WEST MISSISSIPPI BEHAVIORAL SERVICE, LLC
Entity Type:Organization
Organization Name:WEST MISSISSIPPI BEHAVIORAL SERVICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / LLC MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:EDNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-831-2750
Mailing Address - Street 1:3201 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-5350
Mailing Address - Country:US
Mailing Address - Phone:601-636-8006
Mailing Address - Fax:
Practice Address - Street 1:3201 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5350
Practice Address - Country:US
Practice Address - Phone:601-636-8006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility