1538120258 NPI number — PREVENTIVE CARE HEALTH SERVICES LLC

Table of content: (NPI 1538120258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538120258 NPI number — PREVENTIVE CARE HEALTH SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREVENTIVE CARE HEALTH SERVICES 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:
1538120258
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 458
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUNICA
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38676-0458
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-357-7602
Provider Business Mailing Address Fax Number:
662-357-7621

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2073 OLD HIGHWAY 61 N
Provider Second Line Business Practice Location Address:
STE#2
Provider Business Practice Location Address City Name:
TUNICA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38676
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-357-7602
Provider Business Practice Location Address Fax Number:
662-357-7621
Provider Enumeration Date:
03/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FRANKLIN
Authorized Official First Name:
LYDIA
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
NURSE PRACTITIONER
Authorized Official Telephone Number:
662-357-7602

Provider Taxonomy Codes

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

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

  • Identifier: 09015951 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com