Healthcare Provider Details

I. General information

NPI: 1699005983
Provider Name (Legal Business Name): MALL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2010
Last Update Date: 01/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

386 RAYMOND RD BUILDING 30
JACKSON MS
39204-3700
US

IV. Provider business mailing address

350 W WOODROW WILSON AVE SUITE 615
JACKSON MS
39213-7681
US

V. Phone/Fax

Practice location:
  • Phone: 601-982-0673
  • Fax: 601-982-0459
Mailing address:
  • Phone: 601-982-0673
  • Fax: 601-982-0459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. CHRISTAL ROGERS
Title or Position: CLINIC MANAGER
Credential: LPN
Phone: 601-952-0673