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General NPI Number Information
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NPI Number | 1124587829
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Entity Type | Organization
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Legal Business Name | MO SERVICES LLC
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Dates
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Enumeration Date | 03/13/2019
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Last Update Date | 03/13/2019
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Provider Practice Location Address
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Address Line | 15190 COMMUNITY RD. SUITE 120
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City | GULFPORT
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State | MS
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Zip | 39503-3484
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Country | US
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Telephone | 228-328-2400
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Fax | 228-328-4200
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Provider Business Mailing Address
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Address Line | 15190 COMMUNITY RD. SUITE 120
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City | GULFPORT
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State | MS
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Zip | 39503-3484
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Country | US
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Telephone | 228-328-2400
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Fax | 228-328-4200
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Authorized Official
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Title or Position | CEO
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Name | ROBERT LANCE JOHANSEN
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Credential | M.D.
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Telephone | 228-328-2400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207XS0114X
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Taxonomy Name | Adult Reconstructive Orthopaedic Surgery Physician
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License Number |
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License Number State |
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