1023264934 NPI number — BORDERS-BLACKWELL MEDICAL & WELLNESS CORPORATION

Table of content: (NPI 1023264934)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023264934 NPI number — BORDERS-BLACKWELL MEDICAL & WELLNESS CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BORDERS-BLACKWELL MEDICAL & WELLNESS CORPORATION
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:
6
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:
1023264934
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
321 S SHARPE AVE
Provider Second Line Business Mailing Address:
POST OFFICE BOX 1998
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38732
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-843-8700
Provider Business Mailing Address Fax Number:
662-843-9100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
321 S SHARPE AVE
Provider Second Line Business Practice Location Address:
POST OFFICE BOX 1998
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-843-8700
Provider Business Practice Location Address Fax Number:
662-843-9100
Provider Enumeration Date:
08/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BORDERS-BLACKWELL
Authorized Official First Name:
ANNIE
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/PHYSICIAN
Authorized Official Telephone Number:
662-843-8700

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  20725 , 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)

  • Identifier: 07079055 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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