Provider Demographics
NPI:1831174804
Name:LEAKE COUNTY BOARD OF TRUSTEES
Entity type:Organization
Organization Name:LEAKE COUNTY BOARD OF TRUSTEES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-267-1432
Mailing Address - Street 1:310 ELLIS ST
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MS
Mailing Address - Zip Code:39051-3809
Mailing Address - Country:US
Mailing Address - Phone:601-267-1100
Mailing Address - Fax:601-267-1211
Practice Address - Street 1:310 ELLIS ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MS
Practice Address - Zip Code:39051-3809
Practice Address - Country:US
Practice Address - Phone:601-267-1100
Practice Address - Fax:601-267-1211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11-187282N00000X, 282NR1301X, 282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No282N00000XHospitalsGeneral Acute Care Hospital
No282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0220808Medicaid
MS0220809Medicaid
MS0230186Medicaid
MS9016232Medicaid
MS9016253Medicaid
MS0220808Medicaid
MS9016253Medicaid