Provider Demographics
NPI:1689489940
Name:STATE VETERANS AFFAIRS BOARD
Entity type:Organization
Organization Name:STATE VETERANS AFFAIRS BOARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PICCOLAR
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-942-8571
Mailing Address - Street 1:11721 TRADITION PARKWAY
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532
Mailing Address - Country:US
Mailing Address - Phone:601-942-8571
Mailing Address - Fax:
Practice Address - Street 1:11721 TRADITION PARKWAY
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532
Practice Address - Country:US
Practice Address - Phone:601-942-8571
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE VETERANS AFFAIRS BOARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-02-12
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No3336I0012XSuppliersPharmacyInstitutional Pharmacy