Healthcare Provider Details

I. General information

NPI: 1134272693
Provider Name (Legal Business Name): BRANDYWINE HEALTH SERVICES OF MISSISSIPPI, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 07/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 E CHERRY ST
ACKERMAN MS
39735-9795
US

IV. Provider business mailing address

PO BOX 1039
ACKERMAN MS
39735-1039
US

V. Phone/Fax

Practice location:
  • Phone: 662-285-6235
  • Fax: 662-285-2516
Mailing address:
  • Phone: 662-285-6235
  • Fax: 662-285-2516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number
License Number StateMS

VIII. Authorized Official

Name: MR. RAY SHOEMAKER
Title or Position: ADMINISTRATOR
Credential:
Phone: 662-285-6235