1144370552 NPI number — BONITA C. MUSIAL

Table of content: (NPI 1144370552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144370552 NPI number — BONITA C. MUSIAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BONITA C. MUSIAL
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:
1144370552
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 949
Provider Second Line Business Mailing Address:
314 MAIN STREET, SUITE D
Provider Business Mailing Address City Name:
MONTICELLO
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39654-0949
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-587-2785
Provider Business Mailing Address Fax Number:
601-587-7799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
314 MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
MONTICELLO
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39654-0949
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-587-2785
Provider Business Practice Location Address Fax Number:
601-587-7799
Provider Enumeration Date:
01/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MUSIAL
Authorized Official First Name:
BONITA
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
SOLO PRACTITIONER
Authorized Official Telephone Number:
601-587-2785

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  13704 , 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: 00117007 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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