1548539117 NPI number — MALL SERVICES, LLC

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 1548539117 NPI number — MALL SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MALL SERVICES, 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:
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:
1548539117
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 W WOODROW WILSON AVE
Provider Second Line Business Mailing Address:
SUITE 615
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39213-7681
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-982-0673
Provider Business Mailing Address Fax Number:
601-982-0459

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1860 CHADWICK DR
Provider Second Line Business Practice Location Address:
SUITE 305
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39204-3463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-503-4960
Provider Business Practice Location Address Fax Number:
601-982-0459
Provider Enumeration Date:
12/27/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SHIRLEY
Authorized Official First Name:
AARON
Authorized Official Middle Name:
Authorized Official Title or Position:
PROJECT DIRECTOR
Authorized Official Telephone Number:
601-982-0673

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  10119 , 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: 08406271 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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