Basic Information
| Provider Information | |||||||||
| NPI: | 1265812630 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAIN | ||||||||
| FirstName: | CHARNELL | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23666 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392253666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012004790 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1297 W GOVERNMENT ST | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390423048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012004790 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2015 | ||||||||
| LastUpdateDate: | 04/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | TL.0005725 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 3491 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 26767 | MS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.