Healthcare Provider Details

I. General information

NPI: 1609951847
Provider Name (Legal Business Name): EMMANUEL RIDGE CHIROPRACTIC SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 N STATE ST STE 116
JACKSON MS
39206-4825
US

IV. Provider business mailing address

2990 HIGHWAY 49 S STE P
FLORENCE MS
39073-9523
US

V. Phone/Fax

Practice location:
  • Phone: 601-845-3544
  • Fax: 601-845-3636
Mailing address:
  • Phone: 601-845-3544
  • Fax: 601-845-3636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0972
License Number StateMS

VIII. Authorized Official

Name: MRS. BEATRICE A EZEM
Title or Position: PRESIDENT,CEO
Credential: RN, CM,CLNC
Phone: 601-845-3544