Healthcare Provider Details

I. General information

NPI: 1003096488
Provider Name (Legal Business Name): SOUTHERN HEALTH CORP. OF HOUSTON, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2007
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 E MADISON ST
HOUSTON MS
38851-2417
US

IV. Provider business mailing address

PO BOX 626
HOUSTON MS
38851-0626
US

V. Phone/Fax

Practice location:
  • Phone: 662-456-1163
  • Fax: 662-456-1159
Mailing address:
  • Phone: 662-456-1163
  • Fax: 662-456-1159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number12-296
License Number StateMS

VIII. Authorized Official

Name: MS. SHEILA BROCKMAN
Title or Position: CEO
Credential:
Phone: 662-456-3700