Healthcare Provider Details

I. General information

NPI: 1619025269
Provider Name (Legal Business Name): NORTHEAST MS HEALTH CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 EAST BRUNSWICK
BYHALIA MS
38611
US

IV. Provider business mailing address

12 EAST BRUNSWICK AVE. P.O. BOX 698
BYHALIA MS
38611
US

V. Phone/Fax

Practice location:
  • Phone: 662-838-2163
  • Fax: 662-838-7944
Mailing address:
  • Phone: 662-838-2163
  • Fax: 662-838-7944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARJORIE P. MCKINNEY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 662-838-2163