Healthcare Provider Details

I. General information

NPI: 1093637704
Provider Name (Legal Business Name): SENERGETIC MANIFOLD PROTOPLASM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3603 THORN TREE LN
SOUTHAVEN MS
38672-7013
US

IV. Provider business mailing address

3603 THORN TREE LN
SOUTHAVEN MS
38672-7013
US

V. Phone/Fax

Practice location:
  • Phone: 901-643-8625
  • Fax:
Mailing address:
  • Phone: 901-643-8625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number State

VIII. Authorized Official

Name: MRS. CRYSTAL CHERIE SIMPSON -JONES
Title or Position: ORGANIZER
Credential:
Phone: 901-643-8625