1770761728 NPI number — MARY KELLEY INC

Table of content: (NPI 1770761728)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770761728 NPI number — MARY KELLEY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARY KELLEY INC
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:
1770761728
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1901 MISSION 66
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VICKSBURG
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39180
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-636-0097
Provider Business Mailing Address Fax Number:
601-629-9969

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 MISSION 66
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VICKSBURG
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39180
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-636-0097
Provider Business Practice Location Address Fax Number:
601-629-9969
Provider Enumeration Date:
02/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
JOURDAN
Authorized Official First Name:
CECELIA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRES/NP
Authorized Official Telephone Number:
601-636-0097

Provider Taxonomy Codes

  • Taxonomy code: 364SF0001X , with the licence number:  R642193 , 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: 03575561 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com