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General NPI Number Information
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NPI Number | 1881134740
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Entity Type | Organization
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Legal Business Name | GULFPORT WELLNESS CENTER INC
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Dates
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Enumeration Date | 02/26/2017
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Last Update Date | 02/26/2017
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Provider Practice Location Address
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Address Line | 12261 HIGHWAY 49 SUITE 6
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City | GULFPORT
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State | MS
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Zip | 39503-2975
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Country | US
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Telephone | 228-206-0542
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Fax | 228-206-0550
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Provider Business Mailing Address
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Address Line | 12261 HIGHWAY 49 SUITE 6
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City | GULFPORT
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State | MS
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Zip | 39503-2975
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Country | US
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Telephone | 228-206-0542
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Fax | 228-206-0550
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Authorized Official
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Title or Position | PRESIDENT/CFO
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Name | MR. MATTHEW JOSEPH SHANNON
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Credential |
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Telephone | 501-339-6067
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 18668
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License Number State | MS
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