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NPI Code Detail

MEDICARE: GINA H MIXON RD

MEDICARE: GINA H MIXON RD
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
1133V00000XRegistered DietitianD0722MS

Other Identifiers

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

General Provider Information

NPI Number : 1902807720
Entity Type Code : Individual
Provider Name (Legal Business Name) : GINA H MIXON RD
Provider Business Mailing Address
First Line : 11 PLACE ROAD
Second Line :
City : ELLISVILLE
State : MS
Zip : 39437
Country : US
Telephone Number : 601-426-4086
Fax Number : 601-426-4417
Provider Business Practice Location Address
First Line : 1220 JEFFERSON ST
Second Line :
City : LAUREL
State : MS
Zip : 39440-4355
Country : US
Telephone Number : 601-426-4086
Fax Number : 601-426-4417
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/02/2005
Last Update Date : 11/03/2010

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Directions to “ GINA H MIXON RD” Practice Location

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