Healthcare Provider Details

I. General information

NPI: 1184174914
Provider Name (Legal Business Name): MADISON HEALTHPLEX AND SPORTS PERFORMANCE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2016
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 BAPTIST DR
MADISON MS
39110-2030
US

IV. Provider business mailing address

501 BAPTIST DR
MADISON MS
39110-2030
US

V. Phone/Fax

Practice location:
  • Phone: 601-856-7757
  • Fax: 601-944-9780
Mailing address:
  • Phone: 601-856-7757
  • Fax: 601-944-9780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: GREG CENTILLI
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 601-856-7757