Healthcare Provider Details

I. General information

NPI: 1679916183
Provider Name (Legal Business Name): ZACHARY DOUGLAS MYRICK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2013
Last Update Date: 04/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 OLD RIVER PL STE D
JACKSON MS
39202-3435
US

IV. Provider business mailing address

2 OLD RIVER PL STE D
JACKSON MS
39202-3435
US

V. Phone/Fax

Practice location:
  • Phone: 601-944-1130
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: