=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124306774
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MISSISSIPPI STAFF HEALING PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2011
-----------------------------------------------------
Last Update Date | 08/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 427 HIGHWAY 51 N
-----------------------------------------------------
City | BROOKHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39601-2350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-835-9444
-----------------------------------------------------
Fax | 601-833-5210
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 760 SIDNEY TRL SE
-----------------------------------------------------
City | BOGUE CHITTO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39629-9705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-835-6749
-----------------------------------------------------
Fax | 601-833-1633
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | DR. STEPHEN J MILLS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 601-835-6749
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 10780
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------