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General NPI Number Information
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NPI Number | 1063957751
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Entity Type | Organization
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Legal Business Name | AUTOSPA-HEALTHY YOUTH CENTER
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Dates
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Enumeration Date | 01/04/2017
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Last Update Date | 01/04/2017
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Provider Practice Location Address
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Address Line | 1202 DESOTO AVE SUITE A
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City | CLARKSDALE
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State | MS
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Zip | 38614
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Country | US
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Telephone | 662-209-1202
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Fax | 662-483-1627
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Provider Business Mailing Address
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Address Line | 1202 DESOTO AVE SUITE A
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City | CLARKSDALE
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State | MS
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Zip | 38614
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Country | US
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Telephone | 662-209-1202
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Fax | 662-483-1627
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Authorized Official
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Title or Position | PRESIDENT
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Name | GREGORY HOSKINS
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Credential |
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Telephone | 662-209-1202
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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