Provider Demographics
NPI:1932437209
Name:GARDEN PARK
Entity Type:Organization
Organization Name:GARDEN PARK
Other - Org Name:REGION VI MENTAL HEALTH/MENTAL RETARDATION COMMISSION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MADOLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-453-6211
Mailing Address - Street 1:PO BOX 1505
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38935-1505
Mailing Address - Country:US
Mailing Address - Phone:662-453-6211
Mailing Address - Fax:662-455-8724
Practice Address - Street 1:2504 BROWNING ROAD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38935-1505
Practice Address - Country:US
Practice Address - Phone:662-453-6211
Practice Address - Fax:662-455-8724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-25
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770409Medicaid