Healthcare Provider Details

I. General information

NPI: 1407889934
Provider Name (Legal Business Name): LONGWIND PRODUCT & SERVICE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 05/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 W WOODROW WILSON AVE
JACKSON MS
39213-7647
US

IV. Provider business mailing address

PO BOX 11838
JACKSON MS
39283-1838
US

V. Phone/Fax

Practice location:
  • Phone: 601-366-2215
  • Fax: 601-366-9813
Mailing address:
  • Phone: 601-366-2215
  • Fax: 601-366-9813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number06693/11.1
License Number StateMS

VIII. Authorized Official

Name: MR. LONNIE WALKER
Title or Position: CEO
Credential:
Phone: 601-366-2215