Healthcare Provider Details

I. General information

NPI: 1063059988
Provider Name (Legal Business Name): RUSHTON OVERBY HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2019
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 E COUNTY LINE RD STE 520
JACKSON MS
39211-1833
US

IV. Provider business mailing address

5750 JOHNSTON ST STE 502
LAFAYETTE LA
70503-5334
US

V. Phone/Fax

Practice location:
  • Phone: 601-991-9661
  • Fax: 601-991-1916
Mailing address:
  • Phone: 337-294-8081
  • Fax: 337-335-0015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA0633
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number1290
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: