1073807061 NPI number — MARY HAYNES WELLNESS CENTER, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073807061 NPI number — MARY HAYNES WELLNESS CENTER, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARY HAYNES WELLNESS CENTER, 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:
1073807061
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1283 BREEDLOVE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38107-1640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-550-0229
Provider Business Mailing Address Fax Number:
901-794-7877

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5830 MOUNT MORIAH RD
Provider Second Line Business Practice Location Address:
SUITE 18C
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38115-1607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-550-0229
Provider Business Practice Location Address Fax Number:
901-794-7877
Provider Enumeration Date:
06/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
TRAYLOR
Authorized Official First Name:
LINNIE
Authorized Official Middle Name:
REED
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
901-550-0229

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  MD11058 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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