Healthcare Provider Details

I. General information

NPI: 1295488393
Provider Name (Legal Business Name): ON DEMAND MEDICAL TESTING II
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2022
Last Update Date: 01/28/2022
Certification Date: 01/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 OFFICE PARK DR
JACKSON MS
39206-6016
US

IV. Provider business mailing address

4510 OFFICE PARK DR
JACKSON MS
39206-6016
US

V. Phone/Fax

Practice location:
  • Phone: 601-966-5601
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RONALD HEWITT
Title or Position: CEO
Credential:
Phone: 601-966-5601