=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972538460
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN D WISE III
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2006
-----------------------------------------------------
Last Update Date | 11/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 E NORTHSIDE DR SUITE D
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39056-3437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-925-9473
-----------------------------------------------------
Fax | 601-925-9490
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 E NORTHSIDE DR SUITE D
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39056-3437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-925-9473
-----------------------------------------------------
Fax | 601-925-9490
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRINCIPAL
-----------------------------------------------------
Name | MR. JOHN DURR WISE III
-----------------------------------------------------
Credential | C. PED.
-----------------------------------------------------
Telephone | 601-925-9473
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------