=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639395197
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AWAKENINGS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12231 ASHLEY DR SUITE C
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39503-2775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-831-9400
-----------------------------------------------------
Fax | 228-831-9600
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12231 ASHLEY DR SUITE C
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39503-2775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-831-9400
-----------------------------------------------------
Fax | 228-831-9600
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ANTHONY J STOCK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 228-831-9400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 13805
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------