Healthcare Provider Details

I. General information

NPI: 1376929901
Provider Name (Legal Business Name): SW MEDIACAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2015
Last Update Date: 08/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2561 PASS RD SUITE D
BILOXI MS
39531-2125
US

IV. Provider business mailing address

2561 PASS RD SUITE D
BILOXI MS
39531-2125
US

V. Phone/Fax

Practice location:
  • Phone: 228-594-8380
  • Fax: 228-594-8393
Mailing address:
  • Phone: 228-594-8380
  • Fax: 228-594-8393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number097339
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number23941
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR791344
License Number StateMS

VIII. Authorized Official

Name: MRS. ELIZABETH METALF
Title or Position: PRESIDENT
Credential:
Phone: 228-594-8380