NPIMap

Organization Active NPI

Northeast Mental Health-Mental Retardation Commission

Doing business as Lifecore Health Group

  • Rural Health Clinic/Center
  • Tupelo, MS
National Provider Identifier
1548413628
Registry record updated Mar 20, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
NORTHEAST MENTAL HEALTH-MENTAL RETARDATION COMMISSION
Doing business as
Lifecore Health Group
Practice address
2434 S Eason Blvd
Tupelo, MS 38804-6942
Phone
(662) 844-1717
Fax
(662) 680-6416
NPI assigned
Nov 3, 2008
Last updated
Mar 20, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 20, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Steven Stall
Title
Cfo
Phone
(662) 844-1717

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Multi-Specialty Clinic/Center 261QM1300X
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

2434 S Eason Blvd
Tupelo, MS 38804-6942

Mailing address

2434 S Eason Blvd
Tupelo, MS 38804-6942
Phone (662) 844-1717

Other names 1

  • LIFECORE HEALTH GROUP Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040223000473 MS Part B Supplier - Clinic/Group Practice 5193611747 Receives reassigned benefits from 17 practitioners
2 other NPIs on this enrollment
Practice locations: Tupelo, MS

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
25D2003856Lifecore Health Group2434 South Eason Blvd, Tupelo, MS 38804Certificate of waiverFeb 18, 2028

National Provider Directory

National Provider Directory

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

2434 S Eason Blvd
Tupelo, MS 38804
Phone (662) 640-4595

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 16

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1225670400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1395273600000",
    "number": "1548413628",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2434 S EASON BLVD",
            "city": "TUPELO",
            "state": "MS",
            "postal_code": "388046942",
            "telephone_number": "662-844-1717",
            "fax_number": "662-680-6416"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2434 S EASON BLVD",
            "city": "TUPELO",
            "state": "MS",
            "postal_code": "388046942",
            "telephone_number": "662-844-1717",
            "fax_number": "662-680-6416"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHEAST MENTAL HEALTH-MENTAL RETARDATION COMMISSION",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-11-03",
        "last_updated": "2014-03-20",
        "status": "A",
        "authorized_official_last_name": "STALL",
        "authorized_official_first_name": "STEVEN",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "662-844-1717"
    },
    "taxonomies": [
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "LIFECORE HEALTH GROUP",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Tupelo, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 20, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.