Provider Demographics
NPI:1700134624
Name:REGION TEN STATE OF MS
Entity Type:Organization
Organization Name:REGION TEN STATE OF MS
Other - Org Name:WEEMS MENTAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-483-4821
Mailing Address - Street 1:1415 COLLEGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39307
Mailing Address - Country:US
Mailing Address - Phone:601-483-4821
Mailing Address - Fax:
Practice Address - Street 1:1415 COLLEGE DRIVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39307
Practice Address - Country:US
Practice Address - Phone:601-483-4821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGION TEN STATE OF MISSISSIPPI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-27
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018210Medicaid
MS00018210Medicaid