Healthcare Provider Details

I. General information

NPI: 1790331643
Provider Name (Legal Business Name): EPS ON THE GO II
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2019
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5773 OLD CANTON RD
JACKSON MS
39211-3202
US

IV. Provider business mailing address

5773 OLD CANTON RD
JACKSON MS
39211-3202
US

V. Phone/Fax

Practice location:
  • Phone: 601-456-9894
  • Fax:
Mailing address:
  • Phone: 601-456-9894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: EUGENE MORGAN
Title or Position: OWNER/EXERCISE PHYSIOLOGIST
Credential:
Phone: 601-456-9894