Healthcare Provider Details

I. General information

NPI: 1205175908
Provider Name (Legal Business Name): WILLIAM MCCALLISTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2013
Last Update Date: 01/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 RAYMOND RD
JACKSON MS
39204-4203
US

IV. Provider business mailing address

704 FOREST AVE
JACKSON MS
39206-3308
US

V. Phone/Fax

Practice location:
  • Phone: 601-371-1700
  • Fax:
Mailing address:
  • Phone: 769-572-5002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberP326102
License Number StateMS

VIII. Authorized Official

Name: WILLIAM CHARLES MCCALLISTER
Title or Position: LPN
Credential:
Phone: 769-572-5002