Healthcare Provider Details

I. General information

NPI: 1114962560
Provider Name (Legal Business Name): RANKIN BAPTIST ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 07/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5611 HIGHWAY 80 E
PEARL MS
39208
US

IV. Provider business mailing address

5611 HIGHWAY 80 E
PEARL MS
39208
US

V. Phone/Fax

Practice location:
  • Phone: 601-939-6634
  • Fax: 601-420-9252
Mailing address:
  • Phone: 601-939-6634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0323
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0323
License Number StateMS

VIII. Authorized Official

Name: DR. PERRY SANDERFORD
Title or Position: DIRECTOR
Credential: PHD
Phone: 601-939-6634