Healthcare Provider Details

I. General information

NPI: 1841456472
Provider Name (Legal Business Name): MALL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 08/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1066 WIGGINS ROAD
JACKSON MS
39209
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 TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License NumberR656046
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License NumberV-014
License Number StateMS

VIII. Authorized Official

Name: CHERYL R WALKER
Title or Position: CLINIC MANAGER
Credential:
Phone: 601-982-0673