=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689307282
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE RADICAL WITHIN, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2022
-----------------------------------------------------
Last Update Date | 07/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 834 HIGHWAY 12 W # 333
-----------------------------------------------------
City | STARKVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39759-3582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-251-2328
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 834 HIGHWAY 12 W # 333
-----------------------------------------------------
City | STARKVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39759-3582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-251-2328
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | STEPHANIE JANE HOLCOMBE
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 662-251-2328
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------