1255999611 NPI number — BOA VIDA HOSPITAL OF ABERDEEN, MS LLC

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 1255999611 NPI number — BOA VIDA HOSPITAL OF ABERDEEN, MS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOA VIDA HOSPITAL OF ABERDEEN, MS LLC
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:
MRH MEDICAL GROUP, GSV HOULKA
Provider Other Organization Name Type Code:
3
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:
1255999611
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10996 FOUR SEASONS PL STE 100A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CROWN POINT
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46307-8685
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 3RD AVE 32 WEST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HOULKA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-568-2013
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/31/2019

Additional Information

Authorized Official

Authorized Official Last Name:
SINGH
Authorized Official First Name:
KIRNJOT
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
888-339-7339

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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