Healthcare Provider Details

I. General information

NPI: 1114252814
Provider Name (Legal Business Name): MAZLYNN HEATHCARE SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2009
Last Update Date: 10/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 NORTH 2 AVE
HARTFORD AR
36344
US

IV. Provider business mailing address

P O BOX 1104
SLOCOMB AL
36375-1104
US

V. Phone/Fax

Practice location:
  • Phone: 334-714-8384
  • Fax:
Mailing address:
  • Phone: 334-886-7050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateAL

VIII. Authorized Official

Name: MR. BOBBY D PUGH
Title or Position: OWNER
Credential:
Phone: 334-714-8384