Provider Demographics
NPI:1861414781
Name:BOSWELL REGIONAL CENTER
Entity type:Organization
Organization Name:BOSWELL REGIONAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-867-5000
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111-0128
Mailing Address - Country:US
Mailing Address - Phone:601-867-5000
Mailing Address - Fax:601-849-2586
Practice Address - Street 1:1049 SIMPSON HIGHWAY 149 SOUTH
Practice Address - Street 2:
Practice Address - City:MAGEE
Practice Address - State:MS
Practice Address - Zip Code:39111
Practice Address - Country:US
Practice Address - Phone:601-867-5000
Practice Address - Fax:601-849-2586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSBOS-BMR320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770069Medicaid