Healthcare Provider Details

I. General information

NPI: 1316152093
Provider Name (Legal Business Name): PETERRIO HARRIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 HERNANDO ST
SARDIS MS
38666-1010
US

IV. Provider business mailing address

322 HERNANDO ST
SARDIS MS
38666-1010
US

V. Phone/Fax

Practice location:
  • Phone: 662-487-2838
  • Fax:
Mailing address:
  • Phone: 662-487-2838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number33-1155875
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: