1497365100 NPI number — STRIVE THERAPY AND WELLNESS CENTER

Table of content: (NPI 1497365100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497365100 NPI number — STRIVE THERAPY AND WELLNESS CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STRIVE THERAPY AND WELLNESS CENTER
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:
1497365100
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3154 HOOVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLY SPRINGS
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38635-7278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-587-0312
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16068 BOUNDARY DR STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38603-7737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-587-0312
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/06/2020

Additional Information

Authorized Official

Authorized Official Last Name:
QUINLAN
Authorized Official First Name:
KENDALL
Authorized Official Middle Name:
Authorized Official Title or Position:
CPCS
Authorized Official Telephone Number:
775-391-5998

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PENDING . This is a "BCBS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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