Provider Demographics
NPI:1073626511
Name:REGION TEN COMMISSION STATE OF MS
Entity type:Organization
Organization Name:REGION TEN COMMISSION STATE OF MS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDREACCHIO
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:601-483-4821
Mailing Address - Street 1:P.O. BOX 2868
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-2801
Mailing Address - Country:US
Mailing Address - Phone:601-483-4821
Mailing Address - Fax:601-485-8727
Practice Address - Street 1:1415 COLLEGE DRIVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39307-5345
Practice Address - Country:US
Practice Address - Phone:601-483-4821
Practice Address - Fax:601-485-8727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR10-1261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018210Medicaid
MS00018210Medicaid