Healthcare Provider Details

I. General information

NPI: 1912099805
Provider Name (Legal Business Name): SAPHENEIA MEDICAL MINIMALLY INVASIVE THERAPY INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

932 N STATE ST
JACKSON MS
39202-2613
US

IV. Provider business mailing address

932 N STATE ST
JACKSON MS
39202-2613
US

V. Phone/Fax

Practice location:
  • Phone: 601-352-5663
  • Fax: 601-352-4437
Mailing address:
  • Phone: 601-352-5663
  • Fax: 601-352-4437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. RICHARD A MANCILLA
Title or Position: CHIEF OPERATIONS OFFICER
Credential:
Phone: 601-352-5663