1891911186 NPI number — PHYLLIS G KOONCE

Table of content: (NPI 1891911186)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891911186 NPI number — PHYLLIS G KOONCE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYLLIS G KOONCE
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:
COTTON PLANT FAMILY CLINIC
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:
1891911186
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 COUNTY ROAD 714
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLUE MOUNTAIN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38610-9743
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-538-4111
Provider Business Mailing Address Fax Number:
662-538-4128

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 COUNTY ROAD 714
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLUE MOUNTAIN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38610-9743
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-538-4111
Provider Business Practice Location Address Fax Number:
662-538-4128
Provider Enumeration Date:
04/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KOONCE
Authorized Official First Name:
PHYLLIS
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER SOLE PROVIDER
Authorized Official Telephone Number:
662-538-4111

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  R125960 , 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: 06577891 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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