Provider Demographics
NPI:1770938979
Name:TISHOMINGO HEALTH SERVICES, INC.
Entity type:Organization
Organization Name:TISHOMINGO HEALTH SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF LEGAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:TOPPIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-377-4229
Mailing Address - Street 1:456 E PRESIDENT AVE
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-5515
Mailing Address - Country:US
Mailing Address - Phone:662-377-4685
Mailing Address - Fax:
Practice Address - Street 1:296 HIGHWAY 72
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MS
Practice Address - Zip Code:38833-9104
Practice Address - Country:US
Practice Address - Phone:662-427-2073
Practice Address - Fax:662-427-2074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-26
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13-221261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS250002Medicare Oscar/Certification