1356718233 NPI number — HORN LAKE FAMILY PRACTICE

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 1356718233 NPI number — HORN LAKE FAMILY PRACTICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HORN LAKE FAMILY PRACTICE
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:
1356718233
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1019 GOVERNMENT ST
Provider Second Line Business Mailing Address:
SUITE F
Provider Business Mailing Address City Name:
OCEAN SPRINGS
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39564-3860
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-447-3823
Provider Business Mailing Address Fax Number:
228-447-3812

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3102 GOODMAN RD W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HORN LAKE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38637-1172
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-342-6677
Provider Business Practice Location Address Fax Number:
662-342-0203
Provider Enumeration Date:
08/27/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SHARMA
Authorized Official First Name:
SHEETAL
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
662-342-6677

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  14467 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2153358 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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