Provider Demographics
NPI:1912933623
Name:CENTRAL MS SCHOOL BASED HEALTH, LLC
Entity Type:Organization
Organization Name:CENTRAL MS SCHOOL BASED HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:662-289-9404
Mailing Address - Street 1:5264 ATTALA ROAD 1135
Mailing Address - Street 2:
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-6597
Mailing Address - Country:US
Mailing Address - Phone:662-289-9404
Mailing Address - Fax:662-289-6450
Practice Address - Street 1:26050 HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:MC COOL
Practice Address - State:MS
Practice Address - Zip Code:39108-9160
Practice Address - Country:US
Practice Address - Phone:662-289-9404
Practice Address - Fax:662-289-6450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR853619363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSQ04131Medicare UPIN