Healthcare Provider Details

I. General information

NPI: 1447989082
Provider Name (Legal Business Name): PROFESSIONAL QUALITY HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 HIGHWAY 80 W STE 2260
JACKSON MS
39204-2383
US

IV. Provider business mailing address

2310 HIGHWAY 80 W STE 2260
JACKSON MS
39204-2383
US

V. Phone/Fax

Practice location:
  • Phone: 769-867-1455
  • Fax:
Mailing address:
  • Phone: 769-867-1455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name: FREDERICK BERNARD REGINAL
Title or Position: OWNER
Credential:
Phone: 769-867-1455