Healthcare Provider Details

I. General information

NPI: 1598928939
Provider Name (Legal Business Name): BRANDYWINE HEALTH SERVICES OF MISSISSIPPI, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 07/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24224 MS HIGHWAY 15
MATHISTON MS
39752-6876
US

IV. Provider business mailing address

PO BOX 1039
ACKERMAN MS
39735-1039
US

V. Phone/Fax

Practice location:
  • Phone: 662-263-5700
  • Fax: 662-263-5785
Mailing address:
  • Phone: 662-285-6235
  • Fax: 662-285-2516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RAY SHOEMAKER
Title or Position: CEO
Credential:
Phone: 662-285-6235