Basic Information
| Provider Information | |||||||||
| NPI: | 1922127331 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COPAC INCORPORATED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4309 LAKELAND DR | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392328947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018292500 | ||||||||
| FaxNumber: | 6019323857 | ||||||||
| Practice Location | |||||||||
| Address1: | 4309 LAKELAND DR | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392328947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018292500 | ||||||||
| FaxNumber: | 6019323857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 10/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | HUGHES, JR. | ||||||||
| AuthorizedOfficialFirstName: | JERALD | ||||||||
| AuthorizedOfficialMiddleName: | STACY | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6018292500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD, LPC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | FS39-DADA-OP-01 | MS | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 1730289802 | 01 | MS | PHYSICIAN | OTHER | 1073679817 | 01 | MS | NURSE PRACTITIONER | OTHER | 1801997127 | 01 | MS | PHYSICIAN | OTHER | 1316016066 | 01 | MS | PHYSICIAN | OTHER | 0119422 | 05 | MS | MEDICAID | 1235270885 | 01 | MS | COPAC INCORPORATED | OTHER |