Healthcare Provider Details

I. General information

NPI: 1225628985
Provider Name (Legal Business Name): MY BROTHER'S KEEPER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2021
Last Update Date: 01/26/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 E RIVER PL
JACKSON MS
39202-3486
US

IV. Provider business mailing address

805 E RIVER PL
JACKSON MS
39202-3486
US

V. Phone/Fax

Practice location:
  • Phone: 601-500-7660
  • Fax:
Mailing address:
  • Phone: 601-500-7660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MAX MCKINNEY
Title or Position: CFO
Credential:
Phone: 769-216-2455