Provider Demographics
NPI:1063145787
Name:OPEN MINDS COMMUNITY IMPROVEMENT CENTER
Entity type:Organization
Organization Name:OPEN MINDS COMMUNITY IMPROVEMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:ASHIYAH
Authorized Official - Middle Name:
Authorized Official - Last Name:POLK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-731-5156
Mailing Address - Street 1:1003 MERRYDALE DR
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-5422
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1003 MERRYDALE DR
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-5422
Practice Address - Country:US
Practice Address - Phone:228-731-5156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-09
Last Update Date:2022-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health