=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639442726
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOLDEN TRIANGLE GERIATRIC COLLABORATIVE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2012
-----------------------------------------------------
Last Update Date | 02/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 WILBURN WAY
-----------------------------------------------------
City | STARKVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39759-3692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-320-4008
-----------------------------------------------------
Fax | 662-323-6007
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 WILBURN WAY
-----------------------------------------------------
City | STARKVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39759-3692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-320-4008
-----------------------------------------------------
Fax | 662-323-6007
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | DR. MARY ATKINSON SMITH
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 662-320-4008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364SG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Clinical Nurse Specialist
-----------------------------------------------------
License Number | R850904
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------