Provider Demographics
NPI:1912238437
Name:ANCOR CORPORATION
Entity Type:Organization
Organization Name:ANCOR CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BERTRAND
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTOINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-627-5317
Mailing Address - Street 1:500 DESOTO AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-5217
Mailing Address - Country:US
Mailing Address - Phone:662-627-5317
Mailing Address - Fax:
Practice Address - Street 1:500 DESOTO AVE
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-5217
Practice Address - Country:US
Practice Address - Phone:662-627-5317
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-22
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07427785251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07427785Medicaid