1962689042 NPI number — DELTA FOOT CLINICS, INC

Table of content: (NPI 1962689042)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962689042 NPI number — DELTA FOOT CLINICS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DELTA FOOT CLINICS, 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:
THE FOOT 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:
1962689042
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1814 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:
39180-3710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-638-7520
Provider Business Mailing Address Fax Number:
601-638-7541

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1814 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:
39180-3710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-638-7520
Provider Business Practice Location Address Fax Number:
601-638-7541
Provider Enumeration Date:
01/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SHOCKLEY
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
601-638-7520

Provider Taxonomy Codes

  • Taxonomy code: 261QP1100X , with the licence number:  80142 , 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: 4342670001 . This is a "MEDOCARE DME" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 1851563 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 00119033 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 430434140A . This is a "BCBS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 5963224 . This is a "AETNA" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 1540447 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 480026580 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 412865 . This is a "FIRST HEALTH" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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