Provider Demographics
NPI:1023077310
Name:HATTIESBURG HOME CARE SERVICES LLC
Entity type:Organization
Organization Name:HATTIESBURG HOME CARE SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:L
Authorized Official - Last Name:PROFFITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-233-1307
Mailing Address - Street 1:PO BOX 51266
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-1266
Mailing Address - Country:US
Mailing Address - Phone:337-233-1307
Mailing Address - Fax:337-233-5764
Practice Address - Street 1:22 MILLBRANCH RD STE 1200
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1594
Practice Address - Country:US
Practice Address - Phone:601-620-0971
Practice Address - Fax:662-580-4850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11386251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770229Medicaid
MS00770229Medicaid