Healthcare Provider Details

I. General information

NPI: 1356428569
Provider Name (Legal Business Name): MOBILE HEART STATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 TIMBERLANE ROAD
PICAYUNE MS
39466
US

IV. Provider business mailing address

196 TIMBERLANE ROAD
PICAYUNE MS
39466
US

V. Phone/Fax

Practice location:
  • Phone: 601-799-5169
  • Fax: 601-799-3998
Mailing address:
  • Phone: 601-799-5169
  • Fax: 601-799-3998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246XC2903X
TaxonomyVascular Specialist/Technologist Cardiovascular
License NumberARDMS11532
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246XS1301X
TaxonomySonography Specialist/Technologist Cardiovascular
License NumberARDMS11532
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License NumberARDMS
License Number State

VIII. Authorized Official

Name: DR. WAR T VICHAYANOND
Title or Position: PRESIDENT & CEO
Credential: PHD FASE RDCS
Phone: 601-799-5169