Northeast Mental Health-Mental Retardation Commission
Organization Active NPI Rural Health Clinic/Center · Tupelo, MS
NPI 1548413628 · NPPES record last updated Mar 20, 2014
Key facts
- NPI
- 1548413628
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- NORTHEAST MENTAL HEALTH-MENTAL RETARDATION COMMISSION
- Practice address
- 2434 S Eason Blvd
Tupelo, MS 38804-6942 - Phone
- (662) 844-1717
- Fax
- (662) 680-6416
- NPI assigned
- Nov 3, 2008
- Organization subpart
- No
Authorized official
- Name
- Steven Stall
- Title
- Cfo
- Phone
- (662) 844-1717
Other NPIs on the same Medicare enrollment 2
Member of 1
Practitioners 17
-
Sondra Michelle Bennett, PMHNP-BC
-
Ross E Collins Jr., M.D.
-
Lea Ann Hillhouse, LPC
-
Lisa Tyer Kwasinski, LCSW
-
Michael Dean Roberts, PH.D.
-
Aretha M. Northington, PMHNP
-
Melissa Ratliff, M.ED.
-
Susan Duffie, CFNP
-
Katherine E Ederer, PMHNP
-
Lisa D Foley, CFNP
-
Janet Richey, CFNP
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 25D2003856 | Lifecore Health Group | Certificate of waiver | Feb 18, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MS
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
National Provider Directory
Locations
2434 S Eason Blvd
Tupelo, MS 38804
Phone (662) 640-4595
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Multi-Specialty Clinic/Center | 261QM1300X | |||
| Rural Health Clinic/Center | 261QR1300X | Yes |
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 identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 04329807 | Medicaid | MS | |
| 07453596 | Medicaid | MS |
Other names
- LIFECORE HEALTH GROUP
Other providers in Tupelo, MS
- North Mississippi State Hospital Pharmacy
- North Mississippi Vascular Center, PA
- North Ms Emergency Physicians
- Northeast Community Services
- Northeast Mental Health-Mental Retardation Commission
- Northeast Mental Health-Mental Retardation Commission
- Northeast Mental Health/Mental Retardation Commission
- Allison Burks Norwood
- Jessica Ruth Nunley
- Nurse Anesthesia Providers, Inc
All providers in Tupelo, MS · Rural Health Clinic/Center in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 20, 2014. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.