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General NPI Number Information
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NPI Number | 1568468080
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Entity Type | Organization
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Legal Business Name | ELLISVILLE STATE SCHOOL
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Dates
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Enumeration Date | 06/21/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1101 HWY 11 S
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City | ELLISVILLE
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State | MS
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Zip | 39437-4444
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Country | US
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Telephone | 601-477-9384
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Fax | 601-477-5700
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Provider Business Mailing Address
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Address Line | 1101 HWY 11 S
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City | ELLISVILLE
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State | MS
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Zip | 39437-4444
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Country | US
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Telephone | 601-477-9384
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Fax | 601-477-5700
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. SUZIE LASSITER
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Credential |
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Telephone | 601-477-9384
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | C00638
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License Number State | MS
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