1255608816 NPI number — 828 WALK IN CLINIC

Table of content: (NPI 1255608816)

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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