Healthcare Provider Details

I. General information

NPI: 1023324944
Provider Name (Legal Business Name): CHRISTOPHER MORRIS WEAVER LPTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2010
Last Update Date: 08/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 THICKET CV
BELDEN MS
38826-6008
US

IV. Provider business mailing address

1700 THICKET CV
BELDEN MS
38826-6008
US

V. Phone/Fax

Practice location:
  • Phone: 662-617-3771
  • Fax:
Mailing address:
  • Phone: 662-617-3771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberPTA4436
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: