Provider Demographics
NPI:1457376360
Name:MID-DELTA HOME HEALTH OF CHARLESTON, INC.
Entity Type:Organization
Organization Name:MID-DELTA HOME HEALTH OF CHARLESTON, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CLARA
Authorized Official - Middle Name:T
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:662-247-1254
Mailing Address - Street 1:PO BOX 373
Mailing Address - Street 2:
Mailing Address - City:BELZONI
Mailing Address - State:MS
Mailing Address - Zip Code:39038-0373
Mailing Address - Country:US
Mailing Address - Phone:662-247-1254
Mailing Address - Fax:662-247-4924
Practice Address - Street 1:617 N STATE ST
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-6517
Practice Address - Country:US
Practice Address - Phone:662-624-4910
Practice Address - Fax:662-247-4924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS7588251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS70507Medicaid
MS70645OtherBLUE CROSS
MS770448Medicaid
MS770387Medicaid
MS121587Medicaid
MS640718392AOtherDME
MS121587Medicaid
MS770448Medicaid
MS25Q7311007Medicare ID - Type UnspecifiedMARKS
MS257311Medicare ID - Type UnspecifiedPARENT CLARKSDALE
MS70507Medicaid
MS770387Medicaid