1811497464 NPI number — MPOWER HEALING, PLLC

Table of content: (NPI 1811497464)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811497464 NPI number — MPOWER HEALING, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MPOWER HEALING, PLLC
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:
1811497464
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1111
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PICAYUNE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39466-1111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-799-9500
Provider Business Mailing Address Fax Number:
855-675-8575

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 KIRKWOOD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PICAYUNE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39466-3866
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-799-9500
Provider Business Practice Location Address Fax Number:
855-675-8575
Provider Enumeration Date:
02/20/2018

Additional Information

Authorized Official

Authorized Official Last Name:
RICE
Authorized Official First Name:
DESARAE
Authorized Official Middle Name:
SWILLEY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
601-799-9500

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  C6956 , 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: 00584268 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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