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
1679903546
Registry record updated Feb 27, 2020
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
499 Gloster Creek VLG
Suite a-3
Tupelo, MS 38801-4600
Phone
(662) 844-1717
Fax
(662) 680-6416
NPI assigned
Nov 13, 2013
Last updated
Feb 27, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 27, 2020

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

Authorized official

Name
Rita Berthay
Title
Ceo
Phone
(662) 640-4595

Specialties & licenses 2

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

Addresses

Primary practice location

499 Gloster Creek VLG
Suite a-3
Tupelo, MS 38801-4600

Mailing address

2434 S Eason Blvd
Tupelo, MS 38804-6942
Phone (662) 640-4595

Other identifiers 3

IdentifierTypeStateIssuer
0000000MedicaidMS
0000OtherMSBLUE CROSS
000MedicaidMS

Other names 1

  • Lifecore Health Group Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address amerchant@lifecorehealthgroup.com

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
This NPI is an additional NPI on the 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
25D2070628Lifecore Health Group499 Gloster Creek Village Suite a-3, Tupelo, MS 38801Certificate of waiverDec 19, 2027

National Provider Directory

National Provider Directory

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Locations

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

Practitioners & affiliated clinicians

Practitioners 14

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 14

NPI Registry JSON

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

{
    "created_epoch": "1384300800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1582761600000",
    "number": "1679903546",
    "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": "662-640-4595",
            "fax_number": "662-680-6416"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "499 GLOSTER CREEK VLG",
            "address_2": "SUITE A-3",
            "city": "TUPELO",
            "state": "MS",
            "postal_code": "388014600",
            "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": "2013-11-13",
        "last_updated": "2020-02-27",
        "certification_date": "2020-02-27",
        "status": "A",
        "authorized_official_last_name": "BERTHAY",
        "authorized_official_first_name": "RITA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "662-640-4595"
    },
    "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": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0000000",
            "state": "MS"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS",
            "identifier": "0000",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000",
            "state": "MS"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "amerchant@lifecorehealthgroup.com",
            "affiliation": "N",
            "address_1": "499 Gloster Creek Vlg",
            "address_2": "Suite A-3",
            "city": "Tupelo",
            "state": "MS",
            "country_code": "US",
            "postal_code": "388014600",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Lifecore Health Group",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "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 Feb 27, 2020; 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.