Healthcare Provider Details

I. General information

NPI: 1255723730
Provider Name (Legal Business Name): JAMES HOUSTON OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2015
Last Update Date: 02/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2844 TRACELAND DR
TUPELO MS
38801-4200
US

IV. Provider business mailing address

102 MANDI DR
SALTILLO MS
38866-8739
US

V. Phone/Fax

Practice location:
  • Phone: 662-680-3148
  • Fax: 877-276-4918
Mailing address:
  • Phone: 662-680-3148
  • Fax: 877-276-4918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberOT0624
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: