1063786036 NPI number — THE PAIN CLINIC OF MISSISSIPPI, PLLC

Table of content: MS. JULIE LAURA ROSE L.AC., DIPL., MSTCM (NPI 1528328283)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063786036 NPI number — THE PAIN CLINIC OF MISSISSIPPI, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE PAIN CLINIC OF MISSISSIPPI, PLLC
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:
1063786036
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 235019
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTGOMERY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36123-5019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-232-5703
Provider Business Mailing Address Fax Number:
334-395-4110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5903 RIDGEWOOD RD
Provider Second Line Business Practice Location Address:
SUITE 440
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39211-3700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-899-3989
Provider Business Practice Location Address Fax Number:
601-899-3504
Provider Enumeration Date:
03/08/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMSON
Authorized Official First Name:
DUANE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
601-899-3989

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com