Healthcare Provider Details

I. General information

NPI: 1487053740
Provider Name (Legal Business Name): SHATESSIE MARIE FORD CRT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2014
Last Update Date: 10/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E MAIN ST
OKOLONA MS
38860-1529
US

IV. Provider business mailing address

308 S GATLIN ST
OKOLONA MS
38860-2005
US

V. Phone/Fax

Practice location:
  • Phone: 662-322-0340
  • Fax:
Mailing address:
  • Phone: 662-322-0340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number200003542
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: