Healthcare Provider Details

I. General information

NPI: 1689489940
Provider Name (Legal Business Name): STATE VETERANS AFFAIRS BOARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2025
Last Update Date: 02/12/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11721 TRADITION PARKWAY
BILOXI MS
39532
US

IV. Provider business mailing address

11721 TRADITION PARKWAY
BILOXI MS
39532
US

V. Phone/Fax

Practice location:
  • Phone: 601-942-8571
  • Fax:
Mailing address:
  • Phone: 601-942-8571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: PICCOLAR JOHNSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 601-942-8571