Healthcare Provider Details

I. General information

NPI: 1881878577
Provider Name (Legal Business Name): MALL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2007
Last Update Date: 12/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 MAPLE ST
JACKSON MS
39203-3844
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:
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 NumberR729183
License Number StateMS

VIII. Authorized Official

Name: AARON SHIRLEY
Title or Position: DIRECTOR
Credential: MD
Phone: 601-982-0673