Healthcare Provider Details

I. General information

NPI: 1548539117
Provider Name (Legal Business Name): MALL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2011
Last Update Date: 12/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 CHADWICK DR SUITE 305
JACKSON MS
39204-3463
US

IV. Provider business mailing address

350 W WOODROW WILSON AVE SUITE 615
JACKSON MS
39213-7681
US

V. Phone/Fax

Practice location:
  • Phone: 601-503-4960
  • 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 Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number10119
License Number StateMS

VIII. Authorized Official

Name: DR. AARON SHIRLEY
Title or Position: PROJECT DIRECTOR
Credential: M.D.
Phone: 601-982-0673