Healthcare Provider Details

I. General information

NPI: 1821879156
Provider Name (Legal Business Name): RESTORATION COMMUNITY DEVELOPMENT CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2023
Last Update Date: 10/12/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CC ROAD
BELZONI MS
39038
US

IV. Provider business mailing address

308 CAMELLIA LN
INDIANOLA MS
38751-2604
US

V. Phone/Fax

Practice location:
  • Phone: 662-303-1800
  • Fax:
Mailing address:
  • Phone: 662-303-1800
  • Fax: 662-399-5101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: JOANN WILSON
Title or Position: DIRECTOR
Credential:
Phone: 662-303-1800