Healthcare Provider Details

I. General information

NPI: 1821145285
Provider Name (Legal Business Name): STA-HOME HOSPICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 03/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 BRIARWOOD DR SUITE 500
JACKSON MS
39206-3039
US

IV. Provider business mailing address

406 BRIARWOOD DR SUITE 500
JACKSON MS
39206-3039
US

V. Phone/Fax

Practice location:
  • Phone: 601-991-1933
  • Fax: 601-991-3343
Mailing address:
  • Phone: 601-991-1933
  • Fax: 601-991-3343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number023
License Number StateMS

VIII. Authorized Official

Name: MR. GLENN D. WOOD
Title or Position: DIRECTOR OF COMPLIANCE
Credential: RN
Phone: 601-956-5100