=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790954592
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEAVENLY PALACE ADULT CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2008
-----------------------------------------------------
Last Update Date | 02/26/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1654 HIGHWAY 1 N
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38701-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-378-7262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1654 HIGHWAY 1 N
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38703-1943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-378-7262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. PATRICK JACKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 662-378-7262
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number | 07186736
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------