1659316313 NPI number — PRO HEALTH AQUISITION COMPANY

Table of content: (NPI 1659316313)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659316313 NPI number — PRO HEALTH AQUISITION COMPANY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRO HEALTH AQUISITION COMPANY
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:
1659316313
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATER VALLEY
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38965-2946
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-473-3400
Provider Business Mailing Address Fax Number:
662-473-4389

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 N WELLS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KOSCIUSKO
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39090-3637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-290-6020
Provider Business Practice Location Address Fax Number:
662-290-6070
Provider Enumeration Date:
06/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WINDHAM
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
L
Authorized Official Title or Position:
SECRETARY/ TREASURER
Authorized Official Telephone Number:
662-473-3400

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04409521 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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