Healthcare Provider Details

I. General information

NPI: 1235845892
Provider Name (Legal Business Name): SKY INTEGRATIVE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2023
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 FONTAINE PL STE 104
RIDGELAND MS
39157-5189
US

IV. Provider business mailing address

408 FONTAINE PL STE 104
RIDGELAND MS
39157-5189
US

V. Phone/Fax

Practice location:
  • Phone: 601-617-7717
  • Fax: 601-398-0381
Mailing address:
  • Phone: 601-617-7717
  • Fax: 601-398-0381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHAMEKIA BENNETT
Title or Position: MANAGER
Credential: B.S.
Phone: 601-617-7717