1497292205 NPI number — FAMILY FRIEND,LLC

Table of content: (NPI 1497292205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497292205 NPI number — FAMILY FRIEND,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY FRIEND,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:
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:
1497292205
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1504 23RD ST N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39701-2528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-609-4976
Provider Business Mailing Address Fax Number:
662-223-3061

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1504 23RD ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39701-2528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-609-4976
Provider Business Practice Location Address Fax Number:
662-223-3061
Provider Enumeration Date:
01/31/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
STURDIVANT
Authorized Official First Name:
TIFFANY
Authorized Official Middle Name:
RENEE
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
662-609-4976

Provider Taxonomy Codes

  • Taxonomy code: 251J00000X , with the licence number:  1059530 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 253Z00000X , with the licence number: 1059530 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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