1477869881 NPI number — PROVIDENCE PCC OF GRENADA, LLC

Table of content: (NPI 1477869881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477869881 NPI number — PROVIDENCE PCC OF GRENADA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE PCC OF GRENADA, 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:
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:
1477869881
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1855 HILL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRENADA
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38901-5003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-226-8556
Provider Business Mailing Address Fax Number:
662-229-0556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1855 HILL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRENADA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38901-5003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-226-8556
Provider Business Practice Location Address Fax Number:
662-229-0556
Provider Enumeration Date:
08/23/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MITCHELL
Authorized Official First Name:
DEBBIE
Authorized Official Middle Name:
P
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
662-226-8556

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  777 , 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)





Copyright © 2007-2025 www.npivalidator.com