Healthcare Provider Details

I. General information

NPI: 1457582850
Provider Name (Legal Business Name): MR. MILTON SYKES JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2009
Last Update Date: 08/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8213 CAITLIN DR
OLIVE BRANCH MS
38654-8073
US

IV. Provider business mailing address

8213 CAITLIN DR
OLIVE BRANCH MS
38654-8073
US

V. Phone/Fax

Practice location:
  • Phone: 901-581-4925
  • Fax: 662-890-4499
Mailing address:
  • Phone: 901-581-4925
  • Fax: 662-890-4499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number800589962
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: