Healthcare Provider Details

I. General information

NPI: 1255779245
Provider Name (Legal Business Name): CORNELIUS HURD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2429 SOUTHERN DR
GAUTIER MS
39553-6927
US

IV. Provider business mailing address

2429 SOUTHERN DR
GAUTIER MS
39553-6927
US

V. Phone/Fax

Practice location:
  • Phone: 228-218-3112
  • Fax:
Mailing address:
  • Phone: 228-218-3112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: