MEDICARE: MALL SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	R729183	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881878577
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MALL SERVICES, LLC

Provider Business Mailing Address
First Line	:	350 W WOODROW WILSON AVE
Second Line	:	SUITE 615
City	:	JACKSON
State	:	MS
Zip	:	39213-7681
Country	:	US
Telephone Number	:	601-982-0673
Fax Number	:	601-982-0459

Provider Business Practice Location Address
First Line	:	833 MAPLE ST
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39203-3844
Country	:	US
Telephone Number	:	601-982-0673
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	AARON SHIRLEY
Credential	:	MD
Telephone Number	:	601-982-0673

Provider Enumeration Date	:	12/18/2007
Last Update Date	:	12/18/2007

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Directions to “MALL SERVICES, LLC ” Practice Location

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