Healthcare Provider Details

I. General information

NPI: 1548413628
Provider Name (Legal Business Name): NORTHEAST MENTAL HEALTH-MENTAL RETARDATION COMMISSION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2008
Last Update Date: 03/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2434 S EASON BLVD
TUPELO MS
38804-6942
US

IV. Provider business mailing address

2434 S EASON BLVD
TUPELO MS
38804-6942
US

V. Phone/Fax

Practice location:
  • Phone: 662-844-1717
  • Fax: 662-680-6416
Mailing address:
  • Phone: 662-844-1717
  • Fax: 662-680-6416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEVEN STALL
Title or Position: CFO
Credential:
Phone: 662-844-1717