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General NPI Number Information
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NPI Number | 1376840058
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Entity Type | Organization
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Legal Business Name | MISSISSIPPI ADOLESCENT CENTER
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Dates
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Enumeration Date | 02/16/2011
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Last Update Date | 02/16/2011
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Provider Practice Location Address
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Address Line | 760 BROOKMAN DRIVE EXTENSION
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City | BROOKHAVEN
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State | MS
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Zip | 39601-2340
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Country | US
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Telephone | 601-823-5700
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Fax | 601-823-5769
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Provider Business Mailing Address
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Address Line | 760 BROOKMAN DRIVE EXTENSION
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City | BROOKHAVEN
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State | MS
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Zip | 39601-2340
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Country | US
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Telephone | 601-823-5700
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Fax | 601-823-5769
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR, MISSISSIPPI DEP
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Name | MR. EDWIN C. LEGRAND
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Credential | M.A.
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Telephone | 601-359-1288
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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License Number State |
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