1639338577 NPI number — MAGNOLIA REGIONAL COMMUNITY CARE CLINIC

Table of content: MRS. KATHRYN NIKOLAOS KOULIAS P.T. (NPI 1942313895)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639338577 NPI number — MAGNOLIA REGIONAL COMMUNITY CARE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAGNOLIA REGIONAL COMMUNITY CARE CLINIC
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:
1639338577
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 ALCORN DR STE 2C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORINTH
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38834-9073
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-293-7618
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
703 ALCOM DRIVE
Provider Second Line Business Practice Location Address:
109
Provider Business Practice Location Address City Name:
CORINTH
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38834-9302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-293-1680
Provider Business Practice Location Address Fax Number:
662-293-1595
Provider Enumeration Date:
06/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
NELSON
Authorized Official First Name:
HOWARD
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
VP PHYSICAIN SERVICES
Authorized Official Telephone Number:
662-293-7618

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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