1053646190 NPI number — MORE CONVENIENT CARE CENTER LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053646190 NPI number — MORE CONVENIENT CARE CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MORE CONVENIENT CARE CENTER LLC
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:
6
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:
1053646190
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P. O. BOX 68483
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39286
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-321-9104
Provider Business Mailing Address Fax Number:
601-321-9138

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4612 MEDGAR EVERS BLVD
Provider Second Line Business Practice Location Address:
SUITE 10
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39213-5205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-321-9104
Provider Business Practice Location Address Fax Number:
601-321-9138
Provider Enumeration Date:
10/07/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HILLIARD
Authorized Official First Name:
MARY
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
FAMILY NURSE PRACTITIONER
Authorized Official Telephone Number:
601-209-8432

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  R656046 , 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: 500001874 . This is a "MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 00115980 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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