Healthcare Provider Details

I. General information

NPI: 1033143284
Provider Name (Legal Business Name): SOUTH MISSISSIPPI REGIONAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1170 W RAILROAD ST
LONG BEACH MS
39560-4106
US

IV. Provider business mailing address

1170 W RAILROAD ST
LONG BEACH MS
39560-4106
US

V. Phone/Fax

Practice location:
  • Phone: 228-867-1300
  • Fax: 228-214-5563
Mailing address:
  • Phone: 228-867-1300
  • Fax: 228-214-5563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number311
License Number StateMS

VIII. Authorized Official

Name: PAMELA BAKER
Title or Position: DIRECTOR OF FACILITY
Credential: PHD
Phone: 228-867-1300