Healthcare Provider Details

I. General information

NPI: 1164472866
Provider Name (Legal Business Name): WAVERLEY HEALTH CARE CONSULTANTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 BRIARWOOD DR SUITE 410
JACKSON MS
39206-3051
US

IV. Provider business mailing address

PO BOX 12000
JACKSON MS
39236-2000
US

V. Phone/Fax

Practice location:
  • Phone: 601-956-1576
  • Fax:
Mailing address:
  • Phone: 601-956-1576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number0618408
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number0618408
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number0618408
License Number StateMS

VIII. Authorized Official

Name: MR. CHANCEY DUNBAR
Title or Position: SECRETARY / TREASURER
Credential: CPA
Phone: 601-956-1576