=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285716928
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACKSON VA MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 E WOODROW WILSON AVE
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39216-5116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-362-4471
-----------------------------------------------------
Fax | 601-364-1298
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1500 E WOODROW WILSON AVE
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39216-5116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-362-4471
-----------------------------------------------------
Fax | 601-364-1298
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CENTER DIRECTOR
-----------------------------------------------------
Name | DR. RICHARD J BALTZ
-----------------------------------------------------
Credential | D.O
-----------------------------------------------------
Telephone | 601-364-1359
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------