Basic Information
| Provider Information | |||||||||
| NPI: | 1124306774 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISSISSIPPI STAFF HEALING PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 760 SIDNEY TRL SE | ||||||||
| Address2: | |||||||||
| City: | BOGUE CHITTO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396299705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018356749 | ||||||||
| FaxNumber: | 6018331633 | ||||||||
| Practice Location | |||||||||
| Address1: | 427 HIGHWAY 51 N | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396012350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018359444 | ||||||||
| FaxNumber: | 6018335210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2011 | ||||||||
| LastUpdateDate: | 08/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | MILLS | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 6018356749 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 10780 | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0115587 | 05 | MS | MEDICAID |