Provider Demographics
NPI:1134615248
Name:MISSISSIPPI SUPERIOR SENIOR SERVICES
Entity type:Organization
Organization Name:MISSISSIPPI SUPERIOR SENIOR SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LIBERTY
Authorized Official - Middle Name:
Authorized Official - Last Name:FONTANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-255-9225
Mailing Address - Street 1:6340 KILN DELISLE RD STE A
Mailing Address - Street 2:
Mailing Address - City:PASS CHRISTIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39571-9719
Mailing Address - Country:US
Mailing Address - Phone:228-255-9225
Mailing Address - Fax:228-255-7019
Practice Address - Street 1:6340 KILN DELISLE RD STE A
Practice Address - Street 2:
Practice Address - City:PASS CHRISTIAN
Practice Address - State:MS
Practice Address - Zip Code:39571-9719
Practice Address - Country:US
Practice Address - Phone:228-255-9225
Practice Address - Fax:228-255-7019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04755841Medicaid
MS05903259Medicaid