1578717674 NPI number — HISTOLOGY CYTOLOGY TECHNICAL LAB OF NORTH MISSISSIPPI

Table of content: (NPI 1578717674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578717674 NPI number — HISTOLOGY CYTOLOGY TECHNICAL LAB OF NORTH MISSISSIPPI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HISTOLOGY CYTOLOGY TECHNICAL LAB OF NORTH MISSISSIPPI
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578717674
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 428
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OXFORD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38655-0428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-232-8121
Provider Business Mailing Address Fax Number:
662-236-5236

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 S LAMAR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OXFORD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38655-5373
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-232-8121
Provider Business Practice Location Address Fax Number:
662-236-5236
Provider Enumeration Date:
11/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FULLENWIDER
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
SOLE PROPRIETOR
Authorized Official Telephone Number:
800-362-0858

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X , with the licence number:  11854 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com