Provider Demographics
NPI:1982980850
Name:REGION IV CHEMICAL DEPENDENCY COMPLEX
Entity type:Organization
Organization Name:REGION IV CHEMICAL DEPENDENCY COMPLEX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUITIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:SPEARMAN
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:662-286-9883
Mailing Address - Street 1:PO BOX 839
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38835-0839
Mailing Address - Country:US
Mailing Address - Phone:662-286-9883
Mailing Address - Fax:662-286-9836
Practice Address - Street 1:401 NEW HOPE DR
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-7458
Practice Address - Country:US
Practice Address - Phone:662-287-7199
Practice Address - Fax:662-286-8908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018204Medicaid
MS302G700191Medicare PIN