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General NPI Number Information
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NPI Number | 1851730121
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Entity Type | Organization
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Legal Business Name | SONNY MONTGOMER VAMC
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Dates
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Enumeration Date | 06/20/2013
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Last Update Date | 06/20/2013
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Provider Practice Location Address
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Address Line | 1500 E WOODROW WILSON AVE
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City | JACKSON
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State | MS
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Zip | 39216-5116
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Country | US
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Telephone | 601-362-4471
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Fax |
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Provider Business Mailing Address
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Address Line | 1500 E WOODROW WILSON AVE
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City | JACKSON
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State | MS
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Zip | 39216-5116
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Country | US
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Telephone | 601-362-4471
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Fax |
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Authorized Official
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Title or Position | OUTPATIENT LCSW
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Name | MICAH DICKSON TAYLOR
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Credential | LCSW
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Telephone | 601-362-4471
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 284300000X
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Taxonomy Name | Special Hospital
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License Number | C6323
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License Number State | MS
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