Provider Demographics
NPI:1144665738
Name:PROVIDENCE HEALTHCARE OF MS
Entity type:Organization
Organization Name:PROVIDENCE HEALTHCARE OF MS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICH
Authorized Official - Middle Name:
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:601-720-5460
Mailing Address - Street 1:PO BOX 502
Mailing Address - Street 2:
Mailing Address - City:TERRY
Mailing Address - State:MS
Mailing Address - Zip Code:39170-0502
Mailing Address - Country:US
Mailing Address - Phone:601-720-5460
Mailing Address - Fax:601-878-0687
Practice Address - Street 1:6735 I-55 SOUTH FRONTAGE ROAD
Practice Address - Street 2:SUITE 2-A
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272
Practice Address - Country:US
Practice Address - Phone:601-720-5460
Practice Address - Fax:601-878-0687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-08
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR866849251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care