Basic Information
| Provider Information | |||||||||
| NPI: | 1497867857 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISSISSIPPI HOMECARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51266 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705051266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372331307 | ||||||||
| FaxNumber: | 3372335764 | ||||||||
| Practice Location | |||||||||
| Address1: | 2080 S FRONTAGE RD STE 107 | ||||||||
| Address2: | |||||||||
| City: | VICKSBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391805882 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016290015 | ||||||||
| FaxNumber: | 6016290046 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 03/09/2018 | ||||||||
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| AuthorizedOfficialLastName: | STELLY | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3372331307 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 3581 | MS | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 0770602 | 05 | MS | MEDICAID | 70757 | 01 | MS | BLUE CROSS BLUE SHIELD OF | OTHER |