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General NPI Number Information
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NPI Number | 1003582925
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Entity Type | Organization
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Legal Business Name | MY BROTHER'S KEEPER, INC
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Dates
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Enumeration Date | 08/19/2021
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Last Update Date | 08/19/2021
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Provider Practice Location Address
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Address Line | 1221 BRIDGE ST
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City | GULFPORT
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State | MS
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Zip | 39507-3506
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Country | US
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Telephone | 769-216-2455
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Fax |
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Provider Business Mailing Address
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Address Line | 1221 BRIDGE ST
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City | GULFPORT
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State | MS
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Zip | 39507-3506
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Country | US
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Telephone | 769-216-2455
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | JUNE A GIPSON
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Credential |
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Telephone | 769-216-2455
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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