Basic Information
| Provider Information | |||||||||
| NPI: | 1932591518 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SINGING RIVER SERVICES | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3407 SHAMROCK CT | ||||||||
| Address2: | |||||||||
| City: | GAUTIER | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395535337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284970690 | ||||||||
| FaxNumber: | 2284977604 | ||||||||
| Practice Location | |||||||||
| Address1: | 3407 SHAMROCK CT | ||||||||
| Address2: | |||||||||
| City: | GAUTIER | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395535337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284970690 | ||||||||
| FaxNumber: | 2284977604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2015 | ||||||||
| LastUpdateDate: | 02/19/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BLACKWELL | ||||||||
| AuthorizedOfficialFirstName: | SHERMAN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2284970690 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 00018214 | 05 | MS | MEDICAID | 00770256 | 05 | MS | MEDICAID |