1023478435 NPI number — LA MISS DIABETIC SHOES

Table of content: (NPI 1023478435)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023478435 NPI number — LA MISS DIABETIC SHOES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LA MISS DIABETIC SHOES
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:
1023478435
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
139 SOUTHERN RIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39110-9484
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-883-3342
Provider Business Mailing Address Fax Number:
601-856-5955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 HIGHWAY 61 N
Provider Second Line Business Practice Location Address:
SUITE 3400
Provider Business Practice Location Address City Name:
VICKSBURG
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39183-8246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-883-3342
Provider Business Practice Location Address Fax Number:
601-856-5955
Provider Enumeration Date:
02/26/2016

Additional Information

Authorized Official

Authorized Official Last Name:
PHELAN
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
F
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
601-883-3342

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  80145 , 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)





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