Provider Demographics
NPI:1215113956
Name:DESOTO COUNTY OFFICE OF BOARD OF SUPERVISORS
Entity type:Organization
Organization Name:DESOTO COUNTY OFFICE OF BOARD OF SUPERVISORS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-469-8016
Mailing Address - Street 1:830 OLD HIGHWAY 51 N
Mailing Address - Street 2:
Mailing Address - City:NESBIT
Mailing Address - State:MS
Mailing Address - Zip Code:38651-9591
Mailing Address - Country:US
Mailing Address - Phone:662-469-8016
Mailing Address - Fax:662-429-5582
Practice Address - Street 1:6085 HIGHWAY 161
Practice Address - Street 2:
Practice Address - City:WALLS
Practice Address - State:MS
Practice Address - Zip Code:38680-9793
Practice Address - Country:US
Practice Address - Phone:662-469-8016
Practice Address - Fax:662-429-5582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS317341600000X
3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No341600000XTransportation ServicesAmbulanceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ012849Medicaid
MS710650800OtherDOL
MS05100063Medicaid