Healthcare Provider Details

I. General information

NPI: 1275768319
Provider Name (Legal Business Name): SOUTHWEST DEVELOPMENT CORPORATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 06/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 GILCHRIST STREET POST OFFICE BOX 699
FAYETTE MS
39069-0699
US

IV. Provider business mailing address

210 GILCHRIST STREET POST OFFICE BOX 699
FAYETTE MS
39069-0699
US

V. Phone/Fax

Practice location:
  • Phone: 601-786-3955
  • Fax: 601-786-3910
Mailing address:
  • Phone: 601-786-3955
  • Fax: 601-786-3910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number09056303
License Number StateMS

VIII. Authorized Official

Name: MS. MARY T. IRVING
Title or Position: EXECUTIVE DIRECTOR/ADMINISTRATOR
Credential:
Phone: 601-786-3955