Healthcare Provider Details

I. General information

NPI: 1477876530
Provider Name (Legal Business Name): MICK INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2010
Last Update Date: 06/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

334 JOSANNA STREET SUITE #209
JACKSON MS
39202
US

IV. Provider business mailing address

334 JOSANNA STREET SUITE #209
JACKSON MS
39202
US

V. Phone/Fax

Practice location:
  • Phone: 601-974-6085
  • Fax: 601-974-6099
Mailing address:
  • Phone: 601-974-6085
  • Fax: 601-974-6099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL GRACE
Title or Position: MANAGER
Credential:
Phone: 601-974-6085