=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770525057
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VOICE OF CALVARY FAMILY HEALTH CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2006
-----------------------------------------------------
Last Update Date | 05/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 W WOODROW WILSON AVE SUITE 611
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39213-7681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-713-3233
-----------------------------------------------------
Fax | 601-713-2851
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 W WOODROW WILSON AVE SUITE 615
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39213-7681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-982-0673
-----------------------------------------------------
Fax | 601-713-2851
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | PRIMAUS WHEELER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-984-8467
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number | 18106
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------