1255608816 NPI number — 828 WALK IN CLINIC

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 1255608816 NPI number — 828 WALK IN CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
828 WALK IN CLINIC
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:
1255608816
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4594
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BILOXI
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39535-4594
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-273-4096
Provider Business Mailing Address Fax Number:
866-809-7246

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12207 HWY 49
Provider Second Line Business Practice Location Address:
SUITE 40
Provider Business Practice Location Address City Name:
GULFPORT
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-832-8872
Provider Business Practice Location Address Fax Number:
866-809-7246
Provider Enumeration Date:
11/28/2011

Additional Information

Authorized Official

Authorized Official Last Name:
TSANG
Authorized Official First Name:
STACEY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
GENERAL MANAGER
Authorized Official Telephone Number:
228-273-4096

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  R791344 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X , with the licence number: 14282 , 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: 00114733 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 04078379 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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