Healthcare Provider Details

I. General information

NPI: 1245477165
Provider Name (Legal Business Name): MALL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2009
Last Update Date: 01/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W WOODROW WILSON AVE SUITE 615
JACKSON MS
39213-7681
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 Code261Q00000X
TaxonomyClinic/Center
License NumberR656046
License Number StateMS

VIII. Authorized Official

Name: MRS. CHRISTAL ROGERS
Title or Position: OFFICE ASSISTANT
Credential: LPN
Phone: 601-982-0673