1124306774 NPI number — MISSISSIPPI STAFF HEALING 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 1124306774 NPI number — MISSISSIPPI STAFF HEALING PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSISSIPPI STAFF HEALING 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:
1124306774
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
760 SIDNEY TRL SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOGUE CHITTO
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39629-9705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-835-6749
Provider Business Mailing Address Fax Number:
601-833-1633

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
427 HIGHWAY 51 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39601-2350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-835-9444
Provider Business Practice Location Address Fax Number:
601-833-5210
Provider Enumeration Date:
08/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MILLS
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
601-835-6749

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  10780 , 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: 0115587 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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