Healthcare Provider Details

I. General information

NPI: 1679558514
Provider Name (Legal Business Name): MISSISSIPPI STATE DEPARTMENT OF HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 MCINNIS AVE
LEAKESVILLE MS
39451-0489
US

IV. Provider business mailing address

PO BOX 489
LEAKESVILLE MS
39451-0489
US

V. Phone/Fax

Practice location:
  • Phone: 601-394-2694
  • Fax: 601-394-2620
Mailing address:
  • Phone: 601-394-2694
  • Fax: 601-394-2620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number3181
License Number StateMS

VIII. Authorized Official

Name: MRS. MELANIE BOWMAN
Title or Position: DIRECTOR OF HOME HEALTH
Credential: RN
Phone: 601-576-7853