Provider Demographics
NPI:1982811642
Name:STATE VETERANS AFFAIRS BOARD
Entity Type:Organization
Organization Name:STATE VETERANS AFFAIRS BOARD
Other - Org Name:MS STATE VETERANS AFFAIRS BOARD
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DEMETRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-576-4859
Mailing Address - Street 1:PO BOX 3439
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39207-3439
Mailing Address - Country:US
Mailing Address - Phone:601-576-4859
Mailing Address - Fax:601-576-4868
Practice Address - Street 1:660 NORTH ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-3141
Practice Address - Country:US
Practice Address - Phone:601-576-4859
Practice Address - Fax:601-576-4868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC00566Medicare ID - Type Unspecified